Sunday, December 13, 2009

Stand by Me - Musings on conflict between TM professionals

Last updated: 30 Mar. 2014
This blog muses on conflict between health professionals in transfusion medicine (TM) and how to facilitate interdisciplinary teamwork. Given the holiday season, teamwork and ways to promote harmony seem fitting topics. For example, last year's December blog was titled "Let's get together and feel all right" after Bob Marley's classic, One Love.

This month's title comes from a coming-of-age movie with a great soundtrack and a song with the same name - Stand By Me.

Recent events in my home province of Alberta got me to thinking about interdisciplinary teamwork and communication in TM.

In brief, Alberta appears to be in the midst of another experiment in improving patient care or finding ways to save money, depending on your perspective. It's another because we went through something similar with "health care restructuring" in the 1990s.

This time the new 'powers that be' are promoting radical change' in who does what. Probably they want to allocate tasks to the lowest paid worker rather than rationalize who can best perform specific patient care tasks and create exemplary health care teams, but time will tell.

In Canada there is a current controversy surrounding physician assistants (added 22 Jan. 2010). Nurses oppose Ontario government's physician assistant role citing inadequate education, concerns over patient safety and unnecessary costs: 
In recent years, much ink and lip service has been devoted to promoting interdisciplinary teamwork but I wonder how much occurs overall, and in TM in particular, and how effective it is. Some of the issues are discussed in TraQ's Case O-6:
This paper cited in Case O-6 discusses physician / nurse tensions:
This resource from O-6 presents the case of an intern unable to accept advice from an experienced pharmacist:

  • Agency for Healthcare Research and Quality. One dose, 50 pills (Morbidity and Mortality Rounds on the Web)
As well, recently collegues and I have discussed INTD 410, an interdisciplinary course required of all health discipline students at the University of Alberta. As it happens, nursing students take the course later in their programs than medical students and inter-professional tensions occasionally arise, e.g., more experienced nursing students sometimes are tempted to 'gang up' on first year medical students, perhaps to retaliate for perceived or real slights on the wards or perhaps due to assimilating a culture of rivalry.

Over the years I have experienced, firsthand, both minor bickering and significant conflict between clinical staff (nurses and doctors) and technologists in the TM laboratory and continue to hear such anecdotes secondhand. For example, a common anecdote involves physicians (or nurses) being incredibly rude and dictatorial to lab staff who try to uphold safety standards related to patient specimen identity.

My take on this particular scenario is that the front line clinicians are likely under considerable stress treating a badly bleeding patient before their eyes and perceive the lab's "rules" as threatening the patient's life rather than being meant to save it. And it does not help if the laboratory technologist's communication of the issue appears to challenge the clinician's judgement since challenges to authority and competence are seldom viewed favorably by any health professional. Having the technologist be obsequious may be the response that the physician wants but it is not conducive to patient safety.
I briefly discussed tips for how to deal with conflict in this short article written for TraQ years ago:
Effective communication is fundamental to preventing professionals conflicts but a key cause of such conflict is the inability of each professional to appreciate the other's perspective and the realities of each work environment.

The issues are complex, too complex to discuss fully in this blog. Nonetheless, below is food for thought on small ways to start to talk to each other, not at or past each other.

Educational initiatives such as the U of A's INTD 410 course and others can help. Obviously for health professionals to work as a team, they must train as a team.
Collaborative care means collaborative training

Education for interdisciplinary healthcare teams (from TraQ's Case O-6)
But what about those of us who never trained as part of a team and indeed grew up in a family where "we understood the professions as a conventional nuclear family, with doctor-father, nurse-mother, and patient-child"? (Savage & Smith)
As an aside, where do laboratory staff and other so-called "allied health professionals" fit in this cozy nuclear family of yore? Poor country cousins? Backward children kept in the basement and out-of-sight?  
Unseen servants who slave away but are seldom acknowledged even with eye contact, much as cleaning and kitchen staff are in today's hospitals or the homeless on our streets? I'll stop but you get the idea.
For those of us who trained and perhaps still work in such an anachronistic climate, and for educational programs without formal interdisciplinary courses, below are proffered suggestions for baby steps to help our sometimes dysfunctional family.

For facilities with clinical internships, have students spend time shadowing knowledgeable and experienced nurses who administer transfusions. For example, this is done in the TM clinical rotation of MLS students, U of A where the transfusion safety officer happens to be a nurse who is also an MLS graduate.

For hospitals with or without interning technologists, have all lab staff do the same on a rotating basis. In this way, laboratory staff are exposed firsthand to the realities faced by nurses and staff get to know each other as individuals.

Medical students
As part of the often scant exposure to TM received by all medical students, transfusion service laboratories in teaching hospitals can facilitate exposure to the TM laboratory and its staff. This can be done in simple ways, e.g., at the U of A all first year medical and dental students participate in multiple, concurrent group seminars in which transfusion-related cases with TM laboratory data figure prominently.

To facilitate the many students involved, approximately two dozen volunteer facilitators are provided with notes and key learning points and supervise the cases. Besides hematopathologists and hematopathology residents, facilitators also include experienced medical laboratory technologists from the region's blood centre and hospital transfusion services.

Another positive baby step would be for TM-related cases at grand rounds to include components presented by medical laboratory technologists, nurses, and pharmacists, as appropriate.

It's in small ways such as this that interdisciplinary respect has the chance to develop.

As for med students above, nursing students can benefit from clinically relevant lab-focused presentations involving laboratory staff as instructors and facilitators. As well, providing nurses with structured exposures* to the TS lab both during their training and afterwards could serve as the equivalent of technologists shadowing nurse transfusionists.

[* for example, experiences that stress patient and donor blood identity and the consequences of misidentification and how easily it can occur; importance of maintaining blood components in a temperature-controlled environment, etc.]
In Canada increased direct contact between nurses and technologists is facilitated via provincial blood coordinating offices and a network of regional transfusion safety officers, whose numbers include both nurses and technologists.

It's an encouraging sign of the times that the current President of the Canadian Society for Transfusion Medicine is a registered nurse.

Conflict is bound to occur in a work environment involving life and death. It is not a major issue in TM but nevertheless exists. Much remains to be done to break down the mental silos in which TM professionals often work and that sometimes contribute to conflict. Even small steps can help.

Like everything in life, it's hard to demonize someone you can put a face to, have learned something from, and have chatted with in a collegial atmosphere.

As the song from the movie of the same name goes,
Only then can we truly become the Champions of the Transfusion World. (grin)

As always, the views are mine alone. Comments are most welcome.