Very sweetly, family and friends have been asking me about my graduate classes. All I tend to answer is, “it’s awful.” Somewhere in my conception of getting my Doctorate in Nursing Practice (DNP) to become a family nurse practitioner (FNP), I did not think it would be so theoretical. Truly, if I am forced to write the words theoretical framework one more time, I might lose it. (There’s a good chance I may lose it. I have three more major papers to write and more discussion posts and replies than I care to conceptualize.)
It probably doesn’t hep that I’m working full time and even overtime.
Needless to say, it’s been a bit of a stressful fall semester full of papers and readings I don’t want to do. And there’s no end in sight. Next semester is leadership and health policy. I’m really hoping physiology restores my faith in persevering through this program.
And so, dearest reader, that’s why my posts have been a smidgen sporadic. I’m hoping to publish every other Tuesday. I’ve been doing OK, and I hope I don’t let you down! 😀
Despite all my grumbling, it’s not all bad. Despite my frustrations, I am learning a lot about how to make not only my own practice but also health care better.
A few years ago, I read Atul Gawande’s Better: A Surgeon’s Notes on Performance. Gawande has a way with his writing where even though I’m surrounded by patients constantly at work and in theoretical reading at home, I want to read his stuff. A wonderful sampling of his work can be found in this piece and this piece from the New York Times.
In Better, Gawande speaks of various kinds of performance improvement. For one of his chapters, he relays the story of Annie Page, a young girl diagnosed with cystic fibrosis, and the bell curve of cystic fibrosis care in the United States. Essentially, all health care is a bell curve: some care is very excellent, some care is very poor, but most is stunningly average:
The U.S. News and World Report allows only 20 hospitals in the country to make the coveted Honor Roll. Healthgrades ranks 25 cities by its health (and my city of Milwaukee made the cut somehow!) Consumer Reports gives hospital a number, and Leapfrog Hospital Safety Grade gives a letter. And all the scores can be conflicting. How is anyone supposed to find high performing care!?
As coined by Jerry Sternin, we need to look for “positive deviants.”
Sternin was professor of nutrition at Tufts University who studied the efficacy of a Save the Children nutrition program in Vietnam. When funding dried up, Sternin needed the help of the villagers to find the most well-fed children of the poor. He termed mothers of the well-fed children “positive deviants.” Sternin’s program followed the interventions of those mothers and decreased starvation by 65-85% more than the traditional program.
Positive deviants are those people, hospitals, and places that use the resources they have to the best of their ability to find novel ways of doing things for the better. They’re innovators, experimenters, scientists. Oh, man! It’s relating to my school work in saying these people are the flint to start the fire of change per Rogers’ diffusion of innovations theory:
So, I’m trying to use my schoolwork and newfound knowledge to become a positive deviant in my workplace. Too, it’s what Christ encouraged His followers to do all the time. As Walter Ciszek wrote in one of my favorite books, He Leadth Me,
“The kingdom of God will grow upon earth, will be brought to fulfillment, in the same way it was established: by the daily and seemingly hidden lives of those who do always the will of the Father.”
– Walter Ciszek, He Leadth Me
Really, I’ve just got to work on cultivating my little corner of the world, as much as I think I’d be better somewhere else.
They may seem innocuous, but Atul Gawande encourages his readers to become “positive deviants” at the end of Better in the following ways:
- Ask an unscripted question
- Don’t complain
- Count something
- Write something
Gawande is right. Incorporating these small practices has made my little corner of health care better. I hope you can do the same where you are!
Ask an Unscripted Question
Gawande encourages using time in the elevator or even in a patient’s history and physical to ask a question about the other person. Asking unscripted question, he learned a co-worker dated a rock star and supplemented his knowledge of his patients.
I have been asking unscripted questions of my patients for a long time. Somewhere between asking about illicit drug use and breathing while starting an IV and drawing labs, I have time to either sit in silence or ask a question. I inquire about tattoos. I ask what brought people to Milwaukee. Sometimes, I sit in the silence and allow my patients to ask me questions, which are usually about how I got into this job. Regardless of who asks what, it’s allowed me to learn about my patients outside from the acute thing that brought them to my Emergency Department (ED).
It’s worked really well on co-workers too. I ask about holiday plans, kids, where they’ve worked previously, what made them pick this job. I’ve learned a lot about my co-workers. One of my attendings is passionate about fossils to the point where he will corner you and talk about it for 25 minutes when he’s decided you’re tolerable. A nurse I work with loves making cold brew, and once she figures out you love coffee too, she’ll even make it (and very delicious cookies) for you. A tech I work with does theater on the side, and we’ve run lines for her shows together. My orientee loves to knit, and we’ve bonded over the fact that we’re both 27-year old hippie grandmas at heart. (And she even made me a very lovely blanket!)
Unscripted questions break the monotony of patient care. But most importantly, I’ve started to view my co-workers and patients as people not just co-workers and patients. It’s different treating an 88 year-old male and Erwin, an 88 year-old male who ran marathons up to last year, worked as a college professor teaching math, and remembers World War II. Unscripted questions have allowed me to dive into my empathy by understanding more fully who the other person is, what they are passionate about, and their motivations to get better.
This is hard. I’ve been actively trying not to complain for a week or two now, and it is rough. I’m very good at complaining. I mostly complain because I want something like a 3-hour wait for an MRI read for a stroke rule-out to change because 3 hours of not eating and not knowing if your arm weakness is a stoke or radial nerve injury is frightening and unacceptable!
However, there is a major and obvious difference between constructive criticism and plain old griping. Constructive criticism is done to change a system or behavior that is negatively affecting others. Griping is just complaining about something trivial.
This Blessed is She reflection on gossip hit me right in the gut. As writer Olivia Spears wrote, “I think the real reason we gossip is because we mistake it for community.” I also think the real reason we complain at work is we mistake griping for connection.
But is complaining about the weather really helping anyone? Is complaining about the busyness of the day making anything better? Is complaining about a co-worker helping the team atmosphere?
I have attempted to stop complaining, but I keep failing. I’ve found I have used complaining to build connection with my co-workers. But a connection built on mutual disdain of something or someone else is a very weak connection, and I am working on finding the positive or the constructive criticism in every complaint because I want my workplace to be better.
(This is probably why I have a reputation of filling out the most safety event reports in my department. I don’t tolerate 3-hour waits for MRI reads!)
But in learning to stop griping, I’m learning how to compliment. Instead of griping that the ortho consult got the floor dirty from splinting, I compliment the sweet Ortho resident who tried to clean up. Instead of griping about boarding, I compliment the floor nurses that are taking care of the inpatients in the ED. Instead of griping about working Christmas, I compliment all my co-workers who’ve even considered it and have great plans with their families. The connection I’m making being positive and grateful feels like a much stronger connection than the one I built on griping.
Gawande encourages studying something you encounter at your job. I think about the Cardiff study that various EDs in Milwaukee are trying to implement. Essentially, Dr. Jonathan Shepherd, an Oral and Maxillofacial Surgeon, in Cardiff, Wales, noticed he saw the same facial injuries every weekend. He had registrars ask the simple questions of where and when the injury happened. The information was depersonalized and given to local police.
In the study, Shepherd and his research team found that bars served glassware all night. Assailants would break off the handles of pint glasses to assault the victim who would appear in the ED later that night with facial lacerations Shepherd and his team needed to repair. In a 2011 article published by Florence, Shepherd, and Simon called “Effectiveness of anonymised information sharing and use in health service, police, and local government partnership for preventing violence related injury: experimental study and time series analysis” in the BMJ, they found changing a city ordinance to having plastic barware after 11pm reduced these injuries. With this and other innovations based on the data Shepherd collected and gave to police, violent crimes in Cardiff were cut in half between 2002 and 2011.
Shepherd is hailed as an innovator, but truly, all he did was count something. He counted assaults, looked for patterns, and worked with city officials to prevent violence from happening. Helping with the translation study, it’s amazing how hard it has been to implement. Cities have tried and failed. And all the study is asking is that geographic location and time of incident are asked for assault.
I’m hoping to count miscarriages in the ED for my project for school. I really need to talk to my management team and the IRB (which is the Institutional Review Board and just sounds frightening), but I’ve been putting it off. Counting something sounds like a lot of work when you have various hoops to jump through. 😀
Kidding. Gawande encourages writing to find your purpose in the grind. I find writing and reflecting on patient care encourages me to be better. As I wrote recently, “the world does not need more doctors. It needs more doctors that understand poetry.”
Fr. Gordon Gilsdorf taught me the importance of searching for the humanity of others in my work. I’ve found I allow seeds of cynicism and bitterness to grow when I don’t write out what has been going on at work or in my personal life. It helps me to put things in perspective, and I hope this writing is fruitful for you too.
(And hey, if I can get the accolades or money Gawande is getting, that would really help pay for this graduate school!)
Probably the most difficult of all of the suggestions, Gawande encourages his readers to become an early adopter of a new trend. (Rogers’ diffusion of innovations theory again!). We need look for opportunities to grow and change instead of waiting for them to happen to us. Health care is always changing, and there’s always opportunity to spearhead a committee or an innovation.
Looking for change, I was able to jump onto this Cardiff translation study. Looking for change, I was able to jump into a committee re-vamping how we treat women who miscarry within the department. Looking for change, I wrote this post, writing mostly to myself that little choices to make my practice better will make a difference.