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Teamwork - Module 1: Care Relationships - Caring in the Health ProfessionsSo far this unit has focused on one-to-one interactions. Yet ‘defining a scene’ is often a group effort. Goffman says this involves teamwork, with all participants, in effect, agreeing to act and speak within an overall frame of reference. He suggests that it works like a theatrical play in which everyone has taken on a part within the scene.
But what is teamwork? There is a common misconception about the word “teamwork”. Many think it means one co-worker trying to ensure the team’s success by trying to help everyone else do their job, regardless of who does the work and how it gets done. This is not the case; what teamwork should be about, is everyone doing their own job to the best of their ability and pulling together for a common goal.
To play your part means setting aside all those aspects of yourself which are not relevant to your role. The scene works only because everyone plays their part properly and avoids acting in ways which undermine or contradict other people’s performances.
But how can this work? How do people work out who is playing what? Goffman suggests that it happens through a process of people speaking (or doing) in turn and thereby projecting definitions of the situation and of themselves. But they do this in ways that avoid contradicting people’s projections that have preceded theirs.
It is easy to see how junior doctors can see themselves as being the center of everything. The doctor arrives, decisions are taken, and the action begins. Nurses, perhaps cross and impatient about any delay in the doctor’s arrival, will be critical of any failure to take a speedy decision.
"The doctor learns to act (and it is an act, in the beginning at least) quickly and decisively. The adopted persona of decisiveness becomes convincing and the doctor rushes onto the wards, makes the necessary decision, and rushes off again, with smaller tasks perhaps left uncommunicted or undone". (Mackay, 1993, p. 68)
..." a continual effort is made to present a united front through which the patient is kept calm and protected. The way the performance is played is that the doctor has the leading role, the nurse acts as the assistant ... The doctor can question a nurse’s actions ... [but] ... if a nurse were to question a doctor in front of a patient, the doctor’s presentation of confidence and competence would be undermined". (Mackay, 1993, p.112-13)
The previous quotes from Mackay’s research on doctors and nurses present a strong idea of the doctor playing a role, with white coat flying and stethoscope dangling with the medical context described in terms of a little play being enacted in the presence of the patient, in which the doctor is omniscient (or all knowing) and everyone else awaits his wisdom. Does this suggest elements of a theatrical play?
Mackay is talking in terms of a little play enacted in the presence of the patient, in which the doctor is omniscient and everyone else awaits his wisdom
In reality the nurse spends much more time with patients and often knows a lot that the doctor does not. Somehow the nurse needs to be able to communicate essential knowledge to the doctor, in the patient’s presence, without appearing to undermine the doctor’s ‘omniscient’ status. According to Leonard Stein’s research in America, they achieve this through playing ‘the doctor-nurse game’.
The cardinal rule of the game is that open disagreement must be avoided at all cost. Thus, the nurse can communicate her recommendation without appearing to be making a recommendation statement. The physician, in requesting a recommendation from a nurse, must do so without appearing to ask for it. Through subtle teamwork, doctor and nurse together sustain the presentation of an ‘omniscient’ doctor. (Stein, 1978)
The following is a conversation between a Doctor and Nurse in the presence of a patient.
Nurse to patient: This is Dr Jones.
Nurse to doctor: Dr Jones, this is Mrs Brown, who learned today of her father’s death. She is unable to fall asleep
Doctor to nurse: What sleeping medication has been helpful to Mrs Brown in the past?
Nurse to doctor: Pentobarbital mg 100 was quite effective the night before last.
Doctor to nurse: Pentobarbital mg 100 before bedtime as needed for sleep, got it?
Nurse to Doctor: Yes I have, and thank you very much, doctor
The following is an analyses of the communication in the order it takes place:
• Nurse- patient: An open and direct communication.
• Nurse- Doctor: This message has two levels. Openly it describes a set of circumstances: a woman who is unable to fall asleep and who that morning received word of her father’s death. Less openly, but just as directly, it is a diagnostic and recommendation statement: Mrs Brown is unable to sleep because of her grief, and she should be given a sedative.
• Doctor- Nurse: Dr Jones has accepted the diagnostic and recommendation statements but, not knowing the patient, is asking for a further recommendation from Nurse Smith, who does know the patient, about what medication should be prescribed. Note, however, that his question does not appear to be asking her for a recommendation.
• Nurse- Doctor: Nurse Smith makes a disguised recommendation statement.
• Doctor- Nurse: Dr Jones replies with a note of authority in his voice.
• Nurse-doctor: Nurse Smith ends the conversation with the tone of the grateful supplicant.
The patient is entirely passive in this scene. Does that mean that she has no role and is
unimportant to the scene? Does her silence contribute anything?
The patient is actually essential to the scene. It would be unnecessary to play the doctor-nurse game without the patient. But the patient also contributes, simply by accepting her passive role. Her contribution is to defer to both doctor and nurse. Her silence accentuates the busy and assured professional performance going on beside her.
Perhaps Mrs Brown did not want to be sedated, but in the presence of an ‘expert’ nurse, who defers to an even more ‘expert’ doctor, she does not voice an opinion. She seems to understand her role and plays it faithfully.
However, things have been changing since Stein outlined the doctor-nurse game. A more recent study in Sweden reported that:
“In our investigation, the nurses who had been working for 15-20 years often emphasised that it was during the past 8-10 years that marked changes had occurred in their interplay with doctors. Relations in former times are described in terms such as: ‘one had to stand on tiptoe’, ‘the doctors were kings’, or ‘no questioning was allowed’. By contrast today’s relationships are portrayed as collegial; discussion together is common ‘they respect our job’, and ‘they listen and take our views into account’. (Svensson, 1996, p. 383)
But even if the ‘script’ has changed, that does not mean the show has stopped running. It cannot. Nor does this talk of ‘play acting’ imply that what goes on is not serious. Far from it. The central point is that we human beings cannot function together in any other way. We are dependent on ‘making sense of the world’ together. Without shared meanings we cannot act together.