In a previous essay, I spoke about how broad action plans do not work. I mentioned that “be nicer” cannot be a successful action plan. But then I imagined the question, “but how do we make people be nicer?” and said that I had thoughts on that that I would express later. Well, today is the day.
So, how do we make people be nicer? You can’t. Thanks for coming. Shortest essay ever.
What? That’s not good enough? OK, let us dive into this. There are several things that prevent organizations from really locking down a consistent positive demeanor in staff. At the core, though, is the fact that while it seems a simple plan, it is actually complex. While it may seem straightforward, its simplicity is deceptive. When you start piecing apart who owns the initiative, who owns operationalizing, and who will mete out consequences, you realize that it seems impossible to execute without stomping on a lot of people’s toes. At this point, a director, supervisor or manager may quickly determine that this is way above their pay grade and move on to some other target. This is not to say you cannot do something about this, only that you must approach it correctly. There are two broad things to keep in mind as you try to dance in time with the music. There are the understanding of this issue and the definitions we use, and there is the underlying organizational structure that exists that we are relying upon to support this conversation. In this essay, I will focus on the first topic.
Being nice is not always baked in
Healthcare at its core is about service. It is often literally to take care of people in a way that they cannot take care of themselves. This carries with it an unspoken belief in a generosity of spirit that is baked into the healing act. I do believe that this is at the heart of why many people, even most people, get into healthcare. But it isn’t at the heart of all hospital employees. I believe I told this story in a previous essay, but I remember meeting a nurse and I asked her why she was a nurse. She said that she hated her job in retail and after driving past the technical college every day, finally stopped in. The nursing track was the one that was starting first, so, here she was. A month earlier or a month later and she might have been a welder or working in the culinary arts. It may be hard to imagine if you are living in a big city, but there are plenty of smaller towns, where the local hospital is a significant employer and working there feels recession-proof. So not everyone is called to this vocation. Some simply see it as a job.
Think of it in this way. Education, especially primary school education, is similar. It is often seen as a calling and not a job. Teachers are providing a crucial service to future generations and the foundation of this country and its culture. In reading this, I wager that many of you, like me, can think of some wonderful compassionate teachers you encountered who really brought the material to life with their passion. I would reckon you also can remember some absolutely sour individuals who, it felt, treated you like the enemy or an obstacle to overcome. One can ask the question why do something that you clearly hate? And that is the same question you can ask of some in health care.
Even if a person does feel that passion, they may not be the sort of person who wears it on their sleeve. In my experience, doctors are often thought of as not buying into that passion/calling/vocation sentiment. It doesn’t help when many of them seem to complain most about being on-call. But I have also seen many of them become very passionate about the resources available to take care of the patients. They have that burning concern, even if they don’t strike anyone as the warm and fuzzy types. You cannot simply look at an audience and say, “Hey, healthcare, compassion, am I right?” You must understand that some require more effort. So, a strategy designed to reconnect that employee back to their core passion can fail, if that person doesn’t have that core passion, or who is not motivated by that emotional appeal. This does not mean that you cannot motivate them, but only that it requires effort.
Being nice is not the absence of being rude
Most efforts to make staff nicer come from a specific root cause. A senior leader got a letter from a patient complaining about how rude a nurse or a doctor was. Perhaps, after that letter, they happened to notice how many staff members passed in the hallways, not looking up from their phone or the floor. They then had an epiphany that the hospital’s biggest obstacle was that we were not being nice. The problem is that being nice is not simply the absence of rude behavior. It is certainly helpful to, as I am fond of saying, stop punching patients in the face. But that is not what being nice is about.
There are two reasons why no-pass zones don’t generally work. One, I will talk about in the next essay, but the first reason is that they don’t change behaviors and make people nice. For those not familiar with the phrase “no-pass zones” you may be familiar with it under a different name. It is the plan that everyone, when passing anyone in the hallway, will make eye contact and express a verbal greeting. They are popular for two reasons. First, if everyone does it to everyone, it creates a positive atmosphere, where it appears that staff care about patients, family members, and even other staff members. Second, they break the ice. A person will feel reticent to stop an employee whose concentration is elsewhere. But if that employee breaks the ice with eye contact and a head-nod or formal greeting, the person will feel more comfortable stopping them and asking for directions or other assistance.
But while no-pass zones may address an element of perceived rudeness—oblivious staff—it doesn’t actually make people nicer. Consider these examples where the body language does not make this an effective strategy. Two people engaged in a conversation can make eye contact and nod, but this does not make them appear approachable. Those afflicted with the dreaded RBF,1 can make their mouths say ‘hello’ even if the rest of their face doesn’t follow along with the effort. The fast-walkers are yet another group that can execute the letter of the request without bringing any meaning to it by whizzing by before getting a response or acknowledgement.
So, no-pass zones fail because they focus on one small aspect of an encounter without discussing the purpose of the action or calling out the non-verbal aspects to every encounter that may challenge the effectiveness of it. If you have successfully implemented them in your space, well, congratulations! My guess is that you succeeded because you shined a light on the important non-verbal elements, or, because you had a very big stick. [Which we will discuss in the second essay.]
The reality is that even in a hospital that does not honor no-pass zones, there are incredibly nice people providing wonderful interactions with staff and patients. They may or may not be nice to everyone they pass in the halls, but when they engage in a conversation, they can make a patient or coworker feel heard and understood. Those interactions in the hallway may be numerous but are also fleeting. They are also not what drives a patient to call the staff rude. Patients generally reserve that word for extended conversations with staff members in care spaces. This is where your attention should really be directed.
Nice is open to interpretation
Probably the biggest reason why “be nice” fails is because “nice” is a hard word to define. Some of you may roll your eyes at this. How hard is it to define what nice is? You say, “But, Joe, being nice is just being kind, pleasant, agreeable, forgiving.” I would argue that those words are also hard to define. Often people retreat to the truism, “Treat people the way you want to be treated.” I like this because it calls out an important element of being nice—self-reflection—but in practice, this is still dubious advice, since what I want may not be what you want. Better advice is “treat people the way they want to be treated.”
If you think that being nice is a generally understood state of mind, you might imagine, then, that being not-nice is an active choice. But there are a few reasons why someone might not be nice, even someone who might have a reputation for being nice.
Different definitions of nice
I, personally, do not like to be coddled. I get frustrated when someone is trying to give me criticism and they are dancing around it so much, using so many flowery words and run-on sentences that I cannot figure out what they are trying to say. I feel like I am left trying to guess at the nature of their concern. But I also know that this is not how others feel. Some people struggle to get separation from themselves and their work product, so any critiques of their work get misconstrued as personal attacks. While I prefer a blunt approach, it took me a long time to learn that others need more of a dance.2 So treating you the way I want to be treated could lead to hurt feelings. Just as you treating me as you want to be treated will lead to frustration.
Whenever I talk to clinicians about things patients say about them, the most common response is that they are not being rude, they are being honest. They feel that sometimes patients need to hear “if you don’t stop drinking, you will die” or “if you don’t manage your diabetes, you will lose your leg.” While there is always the challenge of walking that direct/rude tightrope, it is clear that some might take offense when you think you are simply calling a spade a spade.
Bad day/personal issues
We are often told to leave our personal problems in the car or our locker and not let them interfere with our workday. I have nothing but respect for everyone who can do that, but for the rest of us, this can be more difficult done than said. This can be especially problematic when you are confronted with situations that really press a button. So, the fact that you have a loved one battling lung cancer may make it difficult to gain separation or perspective when confronted with a smoker who has no interest in quitting.
Lack of Patience
Even the best of us can get worn down over the course of a day, where it feels like we are confronted with the same problems repeatedly. At some point, the smile fades and you just gotta say, “Are you effing kidding me?” If you are dealing with one person continually making the same mistake, your response may be justified. But we often cannot separate that from the common situation, where five different people come to you with the same problem and you treat the fifth person with far less charity than the first person.
Transference/lack of self-reflection
If you have ever managed a group of people, you have likely come across that one person who seems to be immune from any ability to self-reflect. You talk to your team about the need to be attentive to good time clock management by not arriving late, leaving early, or taking long breaks. Then the person in the back of the room who is your BIGGEST CULPRIT at this will pipe up with a “Yeah, you guys need to get better at this, as it hurts the rest of the team because we cannot count on you!” These are the ones who also seem most oblivious to how their behavior might be construed as ‘rude’ to others. Even when you point out the hypocrisy, they are expert at deflection.
Some people just deserve it
While we all strive to be polite to others, we all have limits. We try to be ‘nice’ and solicitous, and the other person is just rude. We respond with kindness and they return with more rudeness. Those with the patience of Job can let the hostility just roll off their backs, but for the rest of us, we will reach our breaking point. In a previous job we had customer service representatives. The sort of people who would work with a client and help them get what they needed and expedite any concerns. As anyone working in that space knows, it always seems like 10% of your clients make 90% of the requests. One rep had one of those high maintenance clients, who would call for a thousand things and expect immediate turnaround. When it didn’t happen immediately, they would want to talk to the person in charge. After managing this client for a while, she finally snapped, and when the client called to complain about some thing not being done, she screamed, “YOU ARE NOT OUR ONLY CLIENT, YOU KNOW!” and hung up on her. While we all appreciated the cathartic feeling of that act, we all knew, her included, that it was her last act as an employee of the company.
In healthcare, this tension can be compounded by the fact that the two people in the conversation are not necessarily coming from a place of centeredness. When an older man comes into the emergency room feet-first on an ambulance gurney, the conversation between the panicked daughter and the stressed ED doctor may not be completely rational or, well, nice.
The reality, then, is that we may all think that being nice is obviously understood and defined, we may not actually be able to define it identically or we may not be able to live to that standard 100% of the time. If you want to create an action plan whose focus is “Be nicer,” you must first confront what that really means and how consistently we can expect people to honor that commitment.
1RBF, for those who are unaware is Resting Bitch Face. The person whose natural face gives others the impression that they are pissed off even though they are not. As a life-long sufferer myself, I have considered starting a GoFundMe to raise resources to find a cure. Until then, just know that if we talk, I am not bored and spending time judging you. It just looks that way.
2To be clear there is a difference between being clear and being rude. Putting a comment on this essay saying, “This essay sucks!” is being rude. Saying, “This essay doesn’t say anything that needed to be said, and its pedantic approach patronizes the reader” is direct. Wrong, but direct.
PX Matters with Joseph Snipp 
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