All the Hospital is a Stage

Whether a hospital refers to this explicitly or not, a lot of patient experience is about staging.  For the purposes of this essay, I will define “staging” as the thoughtful and intentional arrangement of the care spaces, like exam rooms and waiting rooms to reduce anxiety and promote a positive perception of care.  This means both the staging of these public-facing spaces, but also attention to the show that staff are putting on.  Outside of the theatre, I first encountered the term while watching various design shows. ¹ Realtors will furnish rooms, add accents, even bake cookies to evoke certain responses to a home for sale.  Within the realm of my professional career, I first came across this concept in The Experience Economy by B. Joseph Pine II and James H. Gilmore.  This is a book I have referenced before and probably will again.  They call out that the path to success focuses on not just the sale of products but linking those products to an experience that will have your customers prioritize you over other producers.²

For me, in healthcare, I find the book incredibly important.  One reason is in this concept of staging experiences.  In healthcare so much is out of our control.  The number and acuity of patients that present to us.  The way patients’ care can sometimes go sideways.  The issues with staffing and availability of specialists.  The list goes on and on.  With so much of these things that we find ourselves juggling in the delivery of best-practice care, it is all the more important to manage the things that are in our control.  We cannot control when imaging gets backed-up or how long the wait in the emergency department can be.  We CAN however manage how we communicate these things; how we create a space to manage delays or distract patients from the weighty reality of healthcare. 

Before beginning, let me call out one thing.  Some may feel off-put by using language central to theatre or real estate to create an illusion in healthcare.  But this is simply calling out and labelling something that we are already trying to do.  It would be more efficient to house people in the waiting room via long lines of chairs, all facing the same direction.  So why don’t we?  Because that may be efficient in filling a room, it also calls attention to all the wrong things.  We can house fewer patients in the waiting room when we create chairs surrounding a small coffee table for families, or add loveseat chairs or highchairs, for our bariatric patients and those who struggle getting into and out of traditional chairs.  We put in some plants and wall hangings to diffuse the noise along with coffee service and even a fishtank.  All of these things decrease the number of chairs we can have, but we do this to improve the flow and comfort of the space.  Calling it ‘staging’ is simply bringing a simple word to capture a complex set of decisions. 

Further, some may be concerned with the fact that this covers the staff as well as the space.  Our healthcare professionals are not actors.  Again, I think the connotation of this word is more problematic than the reality.  I know that some have a visceral response to the word “scripting” and someday I will take on the concerns over that.  For the moment, though, again, the reality is that asking staff to act in a certain way is exactly what we have been doing forever.  Narrating care is acting.  Paying attention to non-verbal cues in communication is acting.  Building consistency so every patient interaction is the same is acting.  The language may connote a more theatrical approach, but it is, again, simply a framing technique for work already in-place. 

In many ways, healthcare can function within this space, just as any other industry can.  Focusing on the experience is essentially the same as when I talk about focusing on the HOW and not simply the WHAT.  This applies to all settings, from restaurants to retail to manufacturing.  Where healthcare has potentially unique issues is that, in healthcare, everything is on stage where the stage is anywhere that patients can see the show.  While there are places in a hospital where patients or family don’t go, like the lab or the boiler room, a large portion of the hospital is easily accessible by patients and family.  This means that everything that happens here is also easily visible to patients and families.

Nursing stations are generally open-air workspaces with computers on desks in front of pony walls.  Most emergency departments also have open floorplans.  Infusion centers that I have been to have also wide-open spaces, with some half-walls to allow seated patients to feel a bit more secluded.  In all of these spaces, everything that happens is on full display to everyone around.  For those that don’t believe me, read your patient comments.  You will see patients commenting about the general noise at a nursing station or complaining about the inappropriate behavior happening there.³ Patients hear conversations in the hallways or elevators.  Of all the care spaces, clinics are probably the only ones that have fewer open spaces.  While the waiting rooms are still open-concept, the exam rooms are private and generally quiet. 

While I am on record as being suspicious of action plans focusing on eye contact and verbal greetings as we pass people in the hallway, I do think that they have one key value.  They can at least draw attention to the fact that the intense conversation you are having with a colleague as you walk down the hallway is not private.  Having to interrupt yourself by acknowledging someone passing you can force you to take the conversation into a more private setting, if only to maintain your train of thought. 

This “all the healthcare world’s a stage” focus, though, carries a significant problem.  It is exhausting.  Essentially being on-stage for eight or twelve hours at a time is tiring.  It is not just the patient interactions, but the fact that with the open floorplan, even when you are not explicitly interacting with patients and family, you are STILL tacitly interacting with patients and family.  Even in the best of situations, it is impossible to maintain that level of focus and professionalism and healthcare is not the best of situations.  Not only is every patient having a bad day, in their minds, they are having a worse day than any clinician.  Even if the ED is packed and everyone is flying around, the patient assumes that at the end of the shift, all these people get to go home to their family, and this is NOT something that they can assume they will get to do.

No one is perfect and, in this environment, everyone will have their breaking point.  Either in a dramatic and visible way, usually involving impressive strings of profanity.  Or, in a quiet way, by altering how you engage with patients.  I have had countless conversations with emergency department doctors who have said some version of, “The problem is that half of the people who come in here are just drug seekers.”  This sentence is never literally true.  Whether they are saying it for dramatic flair or just a broad frustration, though, it carries two disturbing elements that I will call out.

1. Even if the doctor is hyperbolic, it highlights a state of mind that is troubling. 
   1. They are, mentally, prioritizing these patients.  Some patients are taking up valuable space, rent-free, in the doctor’s head.  Doctors never complain that “the problem is half of the people who come in here have broken legs or congestive heart failure or severe allergic reactions.”  These so-called drug seekers weigh on their minds like no other patients.
   1. The problem is not with the drug seekers themselves, but the fact that this weight bleeds through the next five patients that they see.  While that next patient’s broad abdominal pain could raise a variety of legitimate diagnoses, the first thing the doctor thinks is, “*sigh* Oh, here we go again.”  Even when it turns out to be a bowel obstruction, appendicitis, or a severe muscle strain, their brain still logs it as just “another one.”
2. When they say “half the people who come in here” they have distanced themselves from the work.  They are not people waiting for a bus; they are patients in need of help.  Yes, some don’t need to be here.  But none of them came just to piss the doctor off.  They thought that they needed urgent help.  Or their family thought that they needed help.⁴ Most are not drug seekers.  All of them deserve to be treated with compassion until, or frankly even after, it is proved otherwise. 

Now, you may accuse me of being overly dramatic about a simple turn of phrase.  The point is not to cry foul at every passing comment, though.  I am simply asking you to consider what misunderstandings can manifest from these comments, especially if they are overheard by patients.  Moreover, the point of this is to stress that everyone has their breaking points.  Everyone will snap if they have to be open-minded and engaging to every lunatic that hooves into their field of view in every second of an eight-hour shift.

This is why one of the most important things to consider and plan for when you focus on the staging of a care space is the need for an off-stage space.  Being ON at all times won’t work.  Everyone needs a space to blow off steam,⁵ where they can be themselves out-of-view of anyone who would not understand their reality.  These can be breakrooms, though, it is important that they are structured to be out of eye-line and ear-shot of patients and families.  I visited an inpatient unit that converted a tiny closet into a staff retreat.  The room was just large enough for a comfy chair, mood lighting and a sound machine.  It was a perfect place to center oneself.  Most outpatient surgery centers and some emergency departments have small private consult rooms, where a doctor can give updates to families.  These also can work for this quiet place to let the mask drop for a moment. 

Having them is critical.  If you want to hold staff accountable to behaviors aligned with broad staging goals, you also need to provide staff with a place where they can catch their breath, kick the can, shed a tear or whatever they need for a couple of minutes before returning to the stage.

¹Don’t judge me.  But I do like design shows, both real estate and fashion, as well as cooking shows. 

²This one sentence does not do the book’s central tenet justice.  I talked about it in more detail in another essay, though, so if you are curious, you can read that one.

³When I say, “inappropriate behavior,” I mean from the patient’s perspective.  Things like conversations about last night’s big game or, even loud laughter, can be perceived by some as demonstrating insufficient gravitas for the situation.

⁴I think I am like many people.  I would not go to the emergency department for myself but would quickly take a loved one to the ED, if I didn’t know what was going on.  I joke that my epitaph would read, “I didn’t think it was serious,” a joke of which my wife does NOT think is all that fucking funny.

⁵I say blow off steam, as frustration is the emotion that can get in the way of communication, but even experienced clinical staff confront a wide array of emotions that they would not want to express in front of anyone.