In Practice: Reflections from NPs and PAs

Harrison Reed, PA-C, practices critical care medicine in Baltimore, MD.

You and I have covered a lot of ground this year.

We exposed the fallout of a toxic workplace culture and discussed some of the first steps we can take to fix it. We reestablished respect for our patients. We adjusted some of the biggest problems with our sign-out process. We reminded ourselves of the power of the letter of condolence. And, just for fun, we resolved to lose some of our wordy weight.

All the while, however, we have danced around a more central truth: much of the emotional and psychological damage we accrue in the workplace is inflicted by other healthcare workers. In a field that already struggles against the laws of physics and biology, we complicate our mission with the additional burden of interpersonal conflict. Like the illnesses of so many of our patients, that affliction is preventable.

It’s easy to ignore the problem; denial becomes a refuge. But once we take full responsibility for the toxic behavior in our environment, we can work toward a solution. It will take hundreds of small acts—performed by hundreds of thousands of people—to help nudge our culture in the right direction. Here are a few to get us started:

Mind your manners

I hate to say it, but our parents were right. Manners matter.

Polite society can vanish within the walls of a hospital. We place phone calls without introducing ourselves. We abolish “please” and “thank you” (or mutter it like a curse). We would rather attack than apologize. We act like jerks.

If you want to test just how alien even basic pleasantries are in healthcare, do this: the next time someone from another team or service calls you, ask them how their day is going. That tiny gesture surprises the people I talk to so much that they often stumble over their responses.

A friendly comment can declare a cease-fire when tensions run high or can pick someone up when they are pummeled by stress. It reminds everyone in the room of a simple truth: we are all human.

Roll out the welcome mat

There is nothing worse than the combination of disorientation and isolation that comes from plunging into an unfamiliar environment. And to make matters worse, workplace culture often punishes new employees with additional social penalties or outright hazing.

Even after new employees pay their dues and are welcomed into the fold, it is hard to forget a rocky path to acceptance. Resentment can linger and undermine team cohesion for years. Unfortunately, many of those who experience hazing later replicate the same behavior when the next generation of colleagues joins the workforce.

Someone has to break the cycle. When new employees show up, ensure they feel welcome and included. Establish a clear, positive culture with new recruits from day one—a culture that has no tolerance for abuse.

End tribalism

It feels great to be part of a cohesive team. And one of the surest ways to bring a group together is to focus on a common goal—or a common enemy. Unfortunately, that shortcut to team unity breeds an unpleasant byproduct: rivalry. In healthcare, it’s all too easy to draw lines between “us” and “them.” We form packs based on a variety of criteria: our professions (“doctors vs. nurses”), our specialties (“medicine vs. surgery”), and our institutions (“Everyone vs. Us”).

But, with rare exceptions, we don’t practice medicine in silos. Healthcare is far too complex, far too diverse, and far too interdependent to avoid working with people from other “tribes.” Casting aside these arbitrary differences erases a major barrier to teamwork.

Call it when you see it

Most who work in healthcare, at their core, are great people. But we all need an occasional reminder to clean up our acts when our behavior falls below the standards of our principles. A healthy organization should create mechanisms to call out toxic behavior. Some teams—those with a deep sense of trust and respect—can do this in situ and head off an incident before it escalates. But there should also be a formal pathway to highlight and discuss incidents confidentially after the heat of the moment has passed.

There will always be outliers, individuals who spew toxicity on a regular basis despite warnings. Administrations should lay out clear consequences for repeat offenders—and enforce them as needed. But for most, a gentle reminder is all it takes to keep us all focused on the same goal: helping patients and supporting each other.