There is an old joke that says no one will have as their epitaph, “I wish I cleaned my house more.” The implication is that, when we look back at our lives, we won’t regret enjoying the things that we enjoyed in favor of working harder on the stuff that needed to be done. We often repeat the adage that “All work and no play makes Jack a dull boy” which dates back to at least the 1600s.1 The implication of this is that, if we fail to balance productive work with recreation, we are not being well-rounded. In the past two essays, I have discussed that an obsessive, even exclusive, focus on fixing problems fails because it misunderstands the challenge and encourages us to see our patients as mere caricatures. This essay will focus on the fact that this also has negative impacts on our staff. Not only do they buy into and perpetuate the patient stereotypes discussed in the last essay, they also develop a flawed view of themselves and their approach to the work.
Before I explore this, I feel like I need to state once again that my underlying point is NOT that we should ignore problems. It is interesting that often when you approach a crowd and say, “Hey we should stop focusing exclusively on X,” the response often is, “So you want us to ignore it?” For the third time in three essays, I will say that encouraging a focus on the patient’s entire experience and not just on the failures is not to suggest that we should ignore any negative part of that patient’s experience. We should not ignore the errors, oversights, even incompetence of our staff, but if that is all we focus on, we are also reducing our staff to caricatures.
Fails to Understand the Workday
Ideally, everyone should have at least part of their day that gives them satisfaction. There are some aspects of your job that you look forward to, even if there are parts that you might dread. I often separate these parts of my day as the things that I would do for free and the things that you have to pay me to do. When I was in the classroom, I often said that I would teach for free. I loved the material and the interaction with my students. When the bell rang, I was disappointed that it was over. On the other hand, I was paid to grade papers and exams. Reading fifty exam essays that all said more or less the same thing, while trying to keep a consistent expectation of what an ‘A’ answer was, versus a ‘B’ or ‘C’ answer could be mind-numbing. Reading a stack of research papers about a variety of topics, while again, trying to establish a standard grading rubric was exhausting. Every teacher has to do both, but very few enjoy both tasks equally.
In healthcare, I have heard clinicians express similar divisions. The work includes connecting with patients, collaborating with coworkers, solving problems, doing research, and documenting everything. I imagine many would say that their interactions with staff and patients are the high point of their day, but that the system pays them to document in the electronic health record.
Where this goes sideways is when we find ourselves out-of-balance with the two buckets of work: the shit we shovel and the stuff we adore. I think many of us can relate when a coworker says, “I could literally do nothing all day, except answer emails.” And every time I heard someone say that, they were not celebrating that fact. Some may go further and say, “All I do all day is answer emails.” The first states that, without attention or guardrails, that work could dominate their day. The second dispenses with all pretenses. They are really saying that all day long they are fixing other people’s problems and not doing anything to make things better. How do you tell someone that your job has very little satisfaction without saying that your job has very little satisfaction.
A classic division of work in the patient experience space is to divide the two buckets into two job descriptions. We create a patient advocate role, whose job is to manage the complaints and grievances that the hospital receives, and the patient experience role, whose job is to direct compliance with behavioral must-haves, like hourly rounding, multidisciplinary rounding, or even smiles and eye-contact in the hallway. In places where they divide this work along these lines, the attitude or the vibe of these two teams is radically different. I worked with a hospital that had over 300 beds and they had two people dedicated exclusively to patient advocacy. Over the near-decade of working with them, they burned through patient advocates very quickly. During my time with them, the advocates lasted an average of six months, so they literally had 18 different people in those roles over that time. This may not be surprising, as the work is grueling. The patient stories are depressing, the staff response is often unmotivated, and over time, it feels like you are reading the same complaints with nothing ever getting better. While there are those who might thrive in that environment, most enter the role as a fresh pencil and after six months in the sharpener, they leave as nubbins. Someday, I will write about how to keep that staff motivated and engaged, but for now, I will simply point out that when we see the world as a sea of problems, and our staff as the ones who must fix them, we are a factory that churns out dull boys.
Staff are Impediments not Instruments
If our conversation about the patient experience is focused exclusively on the problems, the gaps, the oversights, the failures, and the missed opportunities, what is the message that this sends our staff? No one jumps out of bed, wipes the sleep from their eyes and says, “I cannot wait to get to work and find out how I failed my organization!” No one relishes the painful dissection of every mistake that we make, especially when it focuses on the stupidity of those making the mistakes and not on how we could have avoided them. When our conversation about the patient experience focuses on this, the message we are sending to our staff is that they are impediments to the organization’s success and not the instruments of the organization’s success.
Not only does this drag down morale, but it also makes it difficult to have a thoughtful conversation about anything. If the only time a leader pulls you aside, or schedules a team meeting, is to discuss your failings, you stop listening to them. From there, you will likely stop trying to improve. After all, if nothing is ever good enough, what is the point? Unfortunately, many of us have had someone in their lives—a boss, a roommate, a family member—who is highly critical, who is quick to blame and slow to praise. You may have tried to work harder to gain their praise, but if it never comes, you eventually tune them out. You might say, “Nothing is ever good enough for you?” and slam the door, or you just ignore them. Either way, going no-carrot, all-stick is not going to be successful in the long-term. At some point, we all need to feel like we are making a difference.
It Defers Joy
For many of us, we have this deeply embedded Calvinist sense that work comes first and play comes after. This may be reasonable, but when we include the additional belief that there is always more work to do, we will find ourselves on an endless treadmill. We must first fix all of the problems before we can enjoy the satisfying parts of our job. But, if there is always more work to do, how often do we get to the satisfying, empowering, parts of our job? By exclusively focusing on the problems that surround us, we continually defer joy. Work becomes an obstacle to our satisfaction.
When I traveled a lot for work, I would drive through downtown to get to the airport. One day, I noticed a new business that opened up; it was an arcade with all the retro video games from my youth. Every time I drove by, I would plan to work extra-hard when I returned, so that I could take a day off and go play, Tempest, Defender, Galaga, Q*Bert, and the rest (IFYKYK). But not surprisingly, there was always another client trip to take and another set of client requests to manage from the last trip. One day, a couple of years later, I drove by and realized that the place had closed. Frankly that depressed me more than the multiple times I drove by it and reminded myself of my commitment. When it was a thing I could do, it kept me going. But when it was gone, I had to confront the fact that all joy had an expiration date.
It is a Loss of Creativity
In a previous essay, I said that a focus on problems was reactive and not proactive. It can feel like one is just moving from one crisis to another without any respite. Its focus can suck the oxygen out of the room; time spent fixing something is time not spent on making something better. Eventually we lose our creativity. We stop figuring out how to change things and only focus on just managing things. Some of us become even worse, because not only are we not being creative, but we are also picking apart the creativity of others. When someone suggests a solution that should minimize issues moving forward, we are trained to identify the eighteen ways that solution won’t work. We don’t think about solutions to those eighteen problems. We simply throw up our hands and give up.
I encourage managers to evaluate how problem-centered their staff is. At the next team meeting, ask your staff, “what kind of [accounting, nursing, lab, fill-in-the-blank] department do you want to see in five years?” Listen to their answers. Do they define their desire in positive or negative terms?
I’ll tell you what I don’t want to see, I don’t want to see mandatory overtime, I don’t want to have to redo work a bunch of times, I don’t want to attend meetings on my off-days, I don’t want to have corporate always looking over our shoulders…
If the team seems focused on defining their ideal workspace as exclusively the absence of negative stimuli, they have lost their creativity, their ability to think about solutions instead of problems. Notice the difference between:
- I don’t want mandatory overtime vs I want an improved staffing structure
- I don’t want a bunch of work re-dos vs I want better lines of two-way communication
- I don’t want off-day meetings vs I want better ways to disseminate important information
- I don’t want obsessive oversight vs I want people to trust my expertise
The positive construction doesn’t contain a solution but provides direction for a solution. It doesn’t have an answer, but at least it doesn’t slam the door on the conversation.
In fact, this issue’s impact on staff causes the other two problems. The mental exhaustion it generates leads staff to stereotype patients, families, or even internal customers as being ignorant or self-centered. Second, it leads to the lack of creativity meaning that we soon only see problems, even when we are talking about improvements. Not only does it defer joy, but it often makes us too tired to celebrate our accomplishments, even if we are attentive enough to notice them. It can lead to a bunker mentality, where we are not just in conflict with our patients, but also with other departments in the organization.2
I wrote last week about how failure is always an option. When we focus on problems alone, we focus only on the things that could lead to our failure. Since we are never going to be 100% perfect, we will inevitably miss something that will lead to failure. Ironically, the best way to avoid failure is to not focus on it and instead focus on things that will breed success. This means not problems, but the path to improvement; not the hole, but the donut.
1Though, given that we are exiting the Halloween season, I most recently reminded of this saying when I rewatched The Shining.
2I remember talking to an inpatient unit manager in Baltimore who described her job exclusively as protecting her staff. The world in her view was full of people who were trying to take advantage of her and getting her team to do other people’s jobs. So, she fought ED admits to her floor, or transfers from other departments. When I asked her who was helping her provide better experiences for patients, she said, “Literally no one. Everyone is working towards our failure.”
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