Oscillating Between Dysfunction and Function in Healthcare

Editor’s note: This text-based course is an edited transcript of the webinar, Oscillating Between Dysfunction Function in Healthcare, presented by Tabitha Ogle, MS, BCC, RRT. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

• Describe leadership the necessary skill set for individual team success
• Recognize strategies for improving RT retention value long term
• Discuss focused areas for growth advancement in the RT profession

Introduction

In this course, we aim to provide awareness and understanding of the multitude of factors that impact functionality within healthcare, particularly for respiratory therapists and other clinical care team workers. By increasing awareness, we create an opportunity for individuals to take control of their reactions, responses, and preparedness in the face of these factors. I have a unique background as an Army-trained respiratory therapist, and I am passionate about advocating for others. With over 15 years of diverse clinical care experience, I have observed various trends within different clinical teams and organizations, which has fueled my curiosity about what truly creates functionality in healthcare.

My employee-first mindset has led me to pursue a degree in industrial organizational psychology. My Master of Science program focuses on analyzing the human aspect within organizations, specifically exploring what enables employees to thrive and what factors contribute to their failure. This academic focus, coupled with my personal experience and observations, has shaped my career goal of advocating for and empowering all of you—the individuals who truly matter in the healthcare system. By sharing this information and knowledge with you, I aim to equip you with the awareness and understanding needed to take control of your reactions, responses, and preparedness within your healthcare roles. Together, we can work towards creating a more functional and supportive healthcare environment for everyone involved.

Oscillating Principle

• Defined as the fluctuation between two things
• Even with ideal working environments empowering mindsets, we must honor that some shifts will be more dysfunctional than others despite external influences from the organization

We all know as respiratory therapists that the oscillating principle is the fluctuation between two things, so how fitting for it to be an oscillation between functionality and dysfunctionality in healthcare. Even with an empowering working environment mindset, we must honor that some clinical shifts will be intensely more dysfunctional than others. By honoring that, we can actively prepare to improve the quality of the area environment in which we work. I will navigate this information to highlight the complexities and the dysfunction and touch on the functionality inside the organization's clinical leadership. After I provide that information, I will give you tools and tips on enhancing your functionality within different clinical teams and supportive work environments.

Oscillating in Healthcare 

• Healthcare is a challenging organization to work in due to a multitude of factors:
  • High emotional cost occupation 
  • Human exchange   
  • Complex working environments
  • Complex working matrix
  • High workloads
  • Lack of or limited resources 

Working in healthcare can be a challenging occupation for various reasons, including the high emotional cost associated with it. Healthcare professionals often find themselves in life-threatening situations where quick and decisive action is required. Dealing with such situations repeatedly over a prolonged period can take a toll on their emotional well-being. The nature of healthcare work involves intense human emotional regulation, control, and interaction. Healthcare providers need to maintain composure and empathy while handling patients who may be in distress or facing serious health issues. This constant emotional exchange can be draining and impact the well-being of healthcare professionals. To address these challenges, there has been a growing focus on patient psychological safety factors in recent years. The advocacy for patient psychological safety aims to create a supportive environment that not only benefits patients but also recognizes the emotional needs of healthcare professionals. By prioritizing psychological safety, healthcare organizations strive to reduce emotional stress and create a more sustainable work environment. High emotional cost occupations typically refer to roles that involve significant face-to-face or voice-to-voice human interaction, such as healthcare, social work, counseling, emergency services, and similar fields. These professions require individuals to navigate complex emotional situations, making self-care and emotional support crucial for those working in these areas. Couple that with the intensity of life or death or medical issues.

We also work in a complex working environment, I am going to touch more on that psychological safety factor aspect. Inside healthcare, we are operating under some really interesting psychological phenomenons, which sounds super cool, but when you look at it, it creates a very complex working environment, the ability for us to function. In the context of a complex working environment, such as healthcare, the status quo bias can indeed contribute to the acceptance of abnormal or abusive working situations. In healthcare, where the focus is primarily on patient care and well-being, it is crucial to address and rectify any issues related to abusive work environments, bullying, operating with a lack of limited resources, working in unhealthy or unregulated working conditions, not being able to get our breaks and other challenges. However, the status quo bias can hinder the willingness or motivation to challenge these norms and bring about necessary changes.

Then that falls with another concept called "group think." Groupthink refers to the phenomenon where a group of people prioritizes consensus and harmony over critical thinking and objective analysis, leading to faulty decision-making. This concept has been observed in various fields, including healthcare. In clinical rounds, it's not uncommon for groupthink to occur, where individuals may hesitate to challenge a statement or decision made by a more authoritative figure. This can happen even if there are concerns about the accuracy or appropriateness of the suggestion. The fear of speaking up or going against the consensus can contribute to the perpetuation of potentially incorrect or suboptimal practices. For example, an advanced care provider states, "Albuterol for CHF," everyone kind of nods along, even though we know that that is not the most appropriate first choice. That falls into a "blame culture." I know a lot of respiratory therapists can resonate with this blame culture inside healthcare. "It is everyone else's fault," instead of sitting back and looking at the problem, trying to find the root cause analysis, "Why did it happen? What can we do to move forward to find a more functional solution?" Instead of doing that, a lot of times, we point fingers, "Well, the nurse never called, or respiratory never showed up." Blame culture can exacerbate the problem of groupthink. When individuals fear blame or retribution for voicing their opinions or suggesting alternative solutions, they may be more inclined to go along with the majority, even if they have reservations. This can hinder the identification of the root causes of issues and impede progress toward finding more effective solutions.

On top of that, we have a complex working matrix inside healthcare. As respiratory therapists, we tend to be a little bit more nomadic. We jump around throughout the hospital, and with that, we get to see these various working matrices. This mobility allows you to interact with various care teams and gain exposure to different working matrices. It can provide you with a broader perspective and a deeper understanding of how different healthcare professionals collaborate to meet the diverse needs of patients. For example, one patient could have a primary physician, a cardiologist, a post-op, and so forth. Each one of those individuals on that care team creates a complex working matrix because everyone has a say in what is going to transpire for this patient. As a result, creates a lot of frustration when you need to communicate something like an arterial blood gas report. You call one physician, they tell you to call another, and you place the note in the chart. The situation where you need to communicate important information but encounter obstacles, such as having to contact multiple physicians or deal with complex care models, is unfortunately common in many hospitals. The high-volume care models in place in most US hospitals can indeed contribute to increased complexity and inefficiency in communication. This can lead to additional tasks and responsibilities for healthcare professionals, further burdening their already busy schedules.

This complex and challenging working environment, particularly in the healthcare industry, creates issues that include high-volume care models, difficulty in interacting and engaging with others, nomadic behaviors such as status quo and groupthink, a blame culture, and a lack of or limited resources. Moreover, the emotional toll of this environment, coupled with a lack of support from the organization, can intensify the challenges faced by healthcare professionals. When time is limited, and there are numerous tasks to be accomplished, it becomes difficult to maintain a high level of compassion and empathy towards patients and colleagues. 

Now when I say resources, that can be a gamut of things. It encompasses various aspects, including human capital (having enough trained and skilled personnel), equipment, education, training, and effective communication channels. These resources are crucial for maintaining a cohesive and collective approach to the job.

In many healthcare organizations, there is often a mission statement that emphasizes innovation and patient care. This mission statement is meant to provide employees with a sense of purpose and connection to something greater than themselves. However, when the organization operates with limited resources and fosters negative emotional exchanges and leadership or employee relationships, it can create mistrust among employees. This mistrust leads to disengagement, which is detrimental in a healthcare setting where active engagement is vital. Conflicting organizational behaviors can also contribute to a toxic work culture. For example, if a hospital promotes itself as the "greatest place to work" while its clinical teams are facing crisis staffing or a massive staffing deficit, it can come across as tone-deaf and lacking awareness of the challenges and conflicts experienced by the clinical teams.

Addressing these issues requires a multi-faceted approach. Organizations should prioritize providing sufficient resources, including staffing, equipment, education, and training, to ensure employees can perform their roles effectively. Open and transparent communication channels should be established to foster understanding and trust within the organization. It's important for leaders to actively address and resolve conflicts, promote a positive work culture, and align their actions with the mission statement to create an environment where employees feel valued and supported.

Organization Complexity 

• Healthcare is in a current life-cycle of growth. 
• The palpable divide between organizational operations clinical care practices. Demonstration of this divide is reflected in high-volume care models. 
• Outdated care models practices.
• Counterintuitive staffing retention practices ultimately cause a decrease in profitability. 
• When we participate in interpersonal conflict or engage in dysfunctional work behavior, the organization ultimately wins.

Organizational complexity inside healthcare, every organization throughout the world goes through what we call business life cycles. Healthcare is currently going through a life cycle of growth. There is a lot of push and pull for different regulations and different requirements. It is in that, like puberty, midlife crisis kind of realm. No one really knows which step to take, adding to that mistrust within the organization. For all of us on the clinical side, we have to honor there is a palpable divide between the organizations' operation and clinical care practice. This is demonstrated and reflected in those high-volume care models, which are not only devastating for employees and patients but are financially counterproductive. On top of that, we have our outdated care model practices. If we know what the best care practice states, but we are not following that, it creates animosity and frustration. Our counterintuitive staffing retention practices ultimately add to that decrease in profitability.

When we as employees participate in those interpersonal conflicts or engage in dysfunctional work behavior, the organization ultimately wins, which sounds crazy when I say it, but here is some information to back up that statement. When we are actively fighting amongst ourselves, creating conflict between ICU and OR, or ICU and ER, or the respiratory day shift, versus respiratory night shift, we become distracted. We are at each other for the issues, it is a lack of support from the organizational structure. If we do not have enough people to do the job, of course, we are going to be at odds with each other because we are all stretched incredibly thin. What is more empowering is to work together and ask for systematic change.

When we are fighting amongst ourselves, the organization wins because it can say, "Listen, healthcare is dysfunctional. That is the way it is." I cannot tell you how many times I have heard that statement out of CEOs CFO, 's and CMOs' mouths. When I say, "We have palpable problems within healthcare," it is okay to admit as long as we focus on the solution-driven efforts to improve it. I always get the rebuttal, "But healthcare's dysfunctional." Well, it is at this time, but like any problem, there is a palpable solution.

Complexity in Leadership 

It is true that clinical leaders face unique challenges in balancing the clinical and organizational aspects of their roles. They often have to navigate between the need to provide quality patient care and manage the resources and budgets within their organizations. One of the key challenges for clinical leaders is the constant pressure to manage budgets effectively while also ensuring adequate staffing levels. This can create tension between clinical needs and financial constraints, making it difficult to strike the right balance. Clinical leaders are often pulled in different directions, as they need to advocate for the resources and staffing necessary to deliver high-quality care while also being mindful of the financial realities of the organization. Employee turnover and burnout are major concerns in healthcare, and clinical leaders have to address these issues within their teams. They must find ways to create a supportive work environment, promote employee well-being, and implement strategies to reduce burnout and turnover rates. Building trust among the staff is crucial, as mistrust within the organization can impede effective leadership and teamwork.

The working environments in healthcare can be complex, with a variety of stakeholders and competing interests. Clinical leaders need to navigate this complexity while ensuring that patient care remains the primary focus. This involves managing relationships with other departments, coordinating care across different specialties, and addressing conflicts or misalignments that may arise. Miscommunication and misinformation can further complicate the leadership role in healthcare. Clinical leaders need to promote clear and effective communication channels within their teams and address any misunderstandings or rumors that can undermine trust and teamwork. They also have to stay updated on the latest research and best practices to ensure that accurate information is being disseminated within the organization. Leadership development is another area of concern. Clinical leaders often have limited opportunities for formal leadership training and development, which can hinder their ability to manage their teams and navigate complex situations effectively. Investing in leadership development programs can help equip clinical leaders with the necessary skills and competencies to succeed in their roles.

Clinical leadership faces a multitude of challenges, including balancing clinical and organizational priorities, managing budgets and staffing, addressing turnover and burnout, building trust and alignment within the organization, navigating complex working environments, addressing miscommunication and misinformation, and investing in leadership development. Effective clinical leaders must be skilled at managing these complexities to ensure the delivery of high-quality care and the success of their teams.

Leaders that Enhance Function

If any of you peruse LinkedIn, you'll hear this array, a rainbow of sorts of various effective leadership strategies that is confusing for clinical leaders who are trying their best to do well but are being pulled in a multitude of directions. Absolutely, when evaluating leadership in any context, including clinical leadership in healthcare, it is important to focus on behaviors and abilities rather than solely relying on personality traits. The qualities and behaviors mentioned are crucial for effective leadership in healthcare settings. Here is a breakdown of the key points:

• Ability to influence and motivate: Effective clinical leaders should possess the skills to inspire and motivate other medical professionals, encouraging them to perform at their best.
• Alignment with organizational mission: Leaders should actively support the mission and goals of the healthcare organization, working towards its overall success.
• Improved patient care: Clinical leaders should prioritize and strive for continuous improvement in patient care outcomes, ensuring that healthcare services meet or exceed standards.
• Following standard procedures: Leaders need to ensure that established protocols and procedures are adhered to, promoting consistency and safety in healthcare delivery.
• Creating a supportive environment: It is important for leaders to foster a supportive environment that respects and values diverse cultural backgrounds and social needs, allowing all individuals to thrive.
• Employee growth and development: Effective leaders invest in the growth and development of their employees, providing opportunities for learning and advancement within the healthcare organization.
• Equality and fairness: Leaders should advocate for equality and fairness, treating all individuals with respect and ensuring equitable opportunities for growth and recognition.
• Advocacy for best practices: Clinical leaders should support and encourage their employees to adopt best practices, staying updated with the latest research and evidence-based approaches in healthcare.

It's important to remember that while not everyone may personally connect or vibe with every leader, the focus should be on their ability to fulfill their role effectively and serve as a resource for their team. By emphasizing these behaviors and qualities, organizations can strive for effective and impactful leadership in the healthcare sector.

Leaders that Create Dysfunction

• Discourage employees’ ability to advocate for patients, staff, or themselves. 
• Intentionally or unintentionally create injustices, mistrust, misalignment, while adding to the chaos. 
• Avoid problems or deflect issues rather than finding the solution.
• Allow an abusive work environment.
• Demonstrate counterproductive work behaviors. 
• Work from a place of ego. 
• Refuse to provide training or employee development

Unfortunately, dysfunctional leadership can have a detrimental impact on organizations and their employees. Your description highlights several negative traits and behaviors that can contribute to dysfunction within a leadership role. Some leaders may indeed discourage employees from advocating for patients, staff, or themselves, which can stifle innovation and prevent necessary changes from being implemented. Leaders who create injustice, mistrust, and misalignment often fail to establish a culture of fairness, transparency, and open communication. This can lead to conflicts, decreased morale, and a lack of cooperation among team members. Additionally, leaders who avoid problems or deflect issues rather than find solutions can perpetuate a cycle of unresolved problems, hindering progress and growth within the organization.

Allowing abusive work environments to persist is not only detrimental to employee well-being but also undermines productivity and organizational success. Counterproductive work behaviors, such as toxic competition or favoritism, can create a hostile atmosphere that hinders collaboration and innovation.

Leaders who operate from a place of ego and prioritize their own interests over the well-being of their team or organization may alienate employees and hinder teamwork and cohesion. Refusing to provide training or employee development opportunities limits growth and can lead to stagnation within the organization.

Overall, dysfunctional leadership behaviors have far-reaching negative consequences and can impede the success and growth of an organization. It is crucial for organizations to recognize and address these issues, fostering a healthy and supportive leadership culture that encourages employee advocacy, growth, and development.

Navigating around the Noise 

Creating awareness is an essential first step in navigating around the challenges described in dealing with leaders or colleagues who may perpetuate patient abuse, staff abuse, or discourage best practices. This is unfortunately reflected in quite a few leaders inside healthcare. Whether it is your direct leader, a nursing director, or a nursing manager, you have to interact with people that sometimes allow for patient abuse to the staff, staff abuse to the staff, discourage you from advocating for best practice, or tell you to brush it off, "that is just the way Dr. Blah Blah Blah is, you have to let it go, or this is how this respiratory therapist is, and you need to let it go." If you do not, I will get into that further, but here are some tools to navigate around this noise. 

Here are some steps you can take to create awareness and address these issues:

• Self-awareness: Start by understanding your own values, principles, and boundaries. Reflect on what you consider to be ethical and professional behavior in healthcare. This self-awareness will help guide your actions and responses.

What is the powerful influence of this person over me? Is this the physician that I feel muted around because they are brass, the way they respond, or out of fear of embarrassment? We have to honor that everyone is a human, and as long as we are performing our job at or above expectation and doing what is right, the likelihood of having negative retaliation for communicating and advocating is low. If it does happen, you have many steps that you can take to re-advocate for yourself. A tool I learned in the military is to respect the person's position. We do not have to respect the person. In the military, I would respect the rank on their chest, but I did not have to like them, I did not have to agree with them, but I could use them as a resource, a tool. That leads to finding those resources. What are these clinical leaders? What is their good spot? What is their gold star? What about them that you can use to learn from, grow from, and develop from? Then define your ideal leader.

The power of influence is something that I learned about when I read a book by Vanessa Bowens. She is a sociologist who documented a lot of her clinical studies that helped us realize how influential we are, how influential behavior is, and how influential a position of power can be to us as human beings. She referenced in her book the "smoke study," commonly known as the "smoke-filled room experiment" or the "smoke-filled classroom experiment." She provided her own insights based on similar research conducted by social psychologists Bibb Latané and John Darley in 1968. In the original experiment, participants were placed in a room and unaware that they were part of a study. The room would gradually fill with smoke, simulating a potential emergency situation. The researchers aimed to observe how individuals reacted when they were alone versus when they were in the presence of others who appeared to be unconcerned.

What the researchers found was that when participants were alone in the room, they tended to react quickly and seek help. However, when they were in the presence of passive bystanders (confederates of the experiment), who did not show any concern or take any action, the participants' response time was significantly delayed. They often hesitated, looked at others for cues, and adopted a more passive attitude. This phenomenon, known as the bystander effect, suggests that individuals are less likely to intervene in an emergency situation when they perceive that others are not reacting or taking action. The diffusion of responsibility and the desire to conform to social norms play important roles in shaping individuals' behavior in such situations. The smoke-filled room experiment highlighted the power of influence and social dynamics in shaping human behavior, particularly in emergencies. It emphasized the importance of individual responsibility and the need to overcome the bystander effect by encouraging pro-social behavior and intervention.

When there were two people alone in that room, the first person in the study saw that the other person was not reacting and ended up only reporting the smoke 10% of the time. When asked after, "Why did not you speak up when you noticed the smoke was filling the room?" They said, "I was embarrassed because they were acting like it was not a big deal. I did not want to make a big deal of it." When they did that with a group of three, only 38% of people spoke up. Now, when they did that alone, 75% of people spoke up. My question to all of you is, "Have you ever muted yourself when you knew something was inappropriate or an emergency out of fear of embarrassment because those around you were not reacting to it? An important point about the expectations we often place on healthcare professionals, such as doctors and nurses, due to their experience, professionalism, and expertise. While it is reasonable to have trust in their abilities, it is equally important for patients and other healthcare professionals to recognize the possibility of mistakes or oversights. No one is infallible, and it is crucial not to silence our concerns or observations when a red flag arises.

The fear of what others may think should not deter us from speaking up when we have genuine concerns about patient care or any other aspect of healthcare. It is better to risk feeling embarrassed or being wrong about something than to remain silent and potentially allow a mistake to occur. Patient safety and well-being should always take precedence over concerns about personal pride. Additionally, it is essential to acknowledge that leaders in healthcare, like any other field, are human beings. Placing them on pedestals and expecting them to have all the answers or be flawless in their decision-making is unrealistic and can lead to disappointment. Recognizing their fallibility and understanding that they, too, can make mistakes allows for a more realistic and collaborative approach to problem-solving and decision-making within healthcare organizations. It is crucial not to mute ourselves when we have concerns in healthcare settings. Speaking up, even if it feels uncomfortable, can help prevent potential errors and promote a culture of accountability and continuous improvement.

Furthermore, understanding that leaders are human and can make mistakes allows for a healthier and more productive work environment. Regardless of how amazing a leader may be, they are still human and prone to making mistakes or taking actions that some may disagree with. However, it is important to acknowledge and appreciate the positive aspects that a leader brings to the functionality of a team or organization, as well as the aspects that enhance dysfunction.

Respecting the position and authority of a leader is crucial for maintaining a productive work environment. Recognizing that they hold the responsibility for managing your schedule, professional development, work culture, and compensation is essential. They are also a valuable resource, possessing a broader range of capabilities and experiences. As such, effective communication with your leader is vital for addressing any issues or concerns related to equipment, personnel, or training. While it is natural to have differences in opinions and potential disagreements, approaching these situations with respect and open communication can lead to better outcomes. It's important to remember that leaders, like everyone else, are not infallible and may make mistakes. Constructive feedback and dialogue can help address any concerns and foster a positive working relationship.

Documenting your concerns and possible solutions via email is a proactive approach to addressing issues you have observed. It provides a clear record of your communication and allows your leader the opportunity to respond professionally and address the concerns raised. If they do not respond appropriately, it's important to maintain a record of your communication for future reference. Limiting the amount of influence a dysfunctional leader has on you is a sensible strategy to protect your own well-being and maintain a healthy work environment. By seeking resources and support from other individuals or departments within the organization, you can mitigate the negative impact of dysfunctional leadership.

Defining your ideal leadership qualities is an excellent step toward personal growth and development. By identifying the traits and qualities you admire in leaders, such as compassion, strong communication, equality, and leading by example, you can work towards embodying those qualities yourself. This self-improvement approach allows you to contribute positively to your work environment and potentially inspire others through your actions. Remember that even in challenging situations, focusing on personal growth and striving to be the best version of yourself can lead to positive outcomes. It's important to stay resilient and seek support from colleagues or mentors who align with your values and goals.

Shift to EMPOWER

• Express yourself. 
• Make your career goals clear.
• Practice professional assertiveness. 
• Own your strengths weakness (humility).
• Work on your communication documentation skills.
• Engage with your support network – define your allies.   
• Request what you the team need to be successful. 

I graduated from respiratory school in the military and received deployment orders within six months of completing my respiratory training. The experience was intensely scary, particularly when I arrived overseas as a female NCO leader, assuming the role of a new respiratory therapist in charge of a respiratory department. In that challenging situation, I took the time to reflect and define my personal vision of a good leader. I actively worked towards embodying that ideal over the past 15 years, hoping that my behavior would positively influence those around me.

To aid me in effective leadership, I found the EMPOWER acronym, developed by Dr. Destiny Petri, an industrial organizational psychologist, to be particularly valuable. The acronym stands for the following: Express yourself professionally, meaning the ability to communicate effectively and create solutions; Make your career goals clear with your leader, articulating your aspirations and intentions, such as advancing to an ICU therapist, then to a shift supervisor, and eventually pursuing specific objectives (e.g., X, Y, Z); Practice professional assertiveness, advocating for yourself even in uncomfortable situations, as growth often arises from such moments; Own your strengths and weaknesses with humility, acknowledging areas for improvement without undue concern about others' opinions. Remember, it is crucial to focus on personal growth rather than worrying about what others may think. By nurturing these qualities, you can cultivate effective leadership skills and foster a positive impact on your environment.

If you are concerned that Nurse Blah Blah Blah may spread the word about your intubation skills, it is important to acknowledge it. It is okay if your intubation skills need improvement. Give yourself the opportunity to grow and enhance this skill, treating it as you would a muscle that needs development. Additionally, focus on improving your communication and documentation skills, which are essential for effective professionalism.
Engaging with a support network and defining your allies is crucial. It is important to note that you do not necessarily need best friends at work, as the popular Gallup survey suggests. Instead, focus on finding allies—individuals with whom you can work cohesively, communicate effectively, and encourage professional growth.

When requesting what your team needs to succeed, practicing professional assertiveness is essential. Transformative changes can occur when we communicate directly rather than speaking behind each other's backs. When you face challenges, such as a nurse picking on you or someone throwing you under the bus, it is best to approach that person and address the issue professionally.
One helpful method for addressing such situations is the "what, what, what now" method. Approach the person and express the issue, stating your frustration with their negative comments and how it hinders your ability to work. Emphasize the importance of open adult communication moving forward, and suggest involving the chain of command if necessary. By standing up for yourself, you make it clear that you will not tolerate such behavior. While their response may vary, advocating for yourself is crucial.

Furthermore, effective and assertive communication skills extend throughout your entire shift, including interactions with advanced care providers. Remember the quote I lived by during deployments: "The smartest person in the code is always the calmest." This does not mean the person lacks awareness of the situation's importance; instead, they recognize the importance of maintaining a sense of calmness to maximize their cognitive abilities. When addressing chaotic situations or problematic behaviors during codes, I have often approached physicians afterward to express how their behavior added unnecessary chaos. I highlighted the need for collective and cohesive communication as a team.

In terms of documentation, do not hesitate to document important matters boldly and proudly. Use strong language to describe what happened, the outcomes, and the actions to be taken moving forward. Personally, I am skilled in effective documentation, especially after speaking with individuals about their actions. For instance, when working in a level II NICU, I encountered a physician who frequently insisted on placing every newborn on 100% FiO2—a grossly inappropriate practice. I directly spoke to him, my management, and his medical director, but he remained adamant.

Consequently, I began documenting these instances. I did so to protect my license and in the hope that someone with influential power would address and rectify the situation. In my documentation, I included details such as "Dr. Blah Blah Blah requested 38-week change to be placed on 100% FiO2 by blow by. Patient saturation prior to FiO2 administration is as follows..." I also expressed my disagreement with the order based on good care practices, standard operating procedures, and hospital regulations. I communicated this to the physician, who insisted on continuing the practice and stated that I would monitor accordingly. Throughout my 15 years as a respiratory therapist, I have documented similar instances in a factual manner. Although I have encountered warnings and confrontations, including a NICU physician who expressed dislike for me, my purpose was not to please individuals or the organization. I was there to provide safe and effective care, honoring the oath I took as a respiratory therapist to "do no harm."

If you are discouraged from documenting such incidents, I encourage you to do it anyway. Ensure that your documentation is objective, without excessive emotions or personal feelings. State the facts. Documentation can also address counterproductive, dangerous, or abusive work behaviors in the hopes of initiating change. While change may not always occur, documenting such incidents can prevent them from burdening you emotionally. For instance, if there is a patient in room seven who is known to be abusive, to throw things, cuss, or yell at staff, document it in your notes, send emails, inform the charge nurse, and ensure you document your communication with the charge nurse. They may say, "Oh, we already know about that, you do not need to write it in there, or Everybody knows, you do not need to write it," but how many people have they told, "We already know," how many people are actually documenting it in there? Despite potential discouragement, persist in your documentation efforts, as it may not be as widely known or acknowledged as they claim.

Functional Teams in Healthcare

Functional teams possess specific characteristics, and I will cover their functions and dysfunctions and provide you with tools to navigate these dynamics. In healthcare, being a nomad can be powerful as it allows you to explore different units within the hospital. This enables you to observe how different units function, understand their collective behavior, and identify any deficits that may exist. However, at the core of functional teams lies trust. Trust facilitates effective communication, ensuring that information is conveyed in a way that promotes action. Functional teams also create a supportive work environment, strive for happy and functional working conditions, and possess the ability to collaborate despite limited resources. They foster positive emotional and psychological safety within the hospital.

Moreover, functional teams have the capacity to perform their jobs and share knowledge, resources, tools, and training while working together cohesively for the benefit of patients and the unit as a whole. They exhibit coordination and collective effort in achieving their goals. Building trust within a team is essential, and effective communication plays a pivotal role in this process. Teaching people how to treat you and setting expectations of behavior around you are crucial aspects of fostering trust.

Dysfunctional Teams in Healthcare 

• Counterproductive work behaviors. 
• Judgement vs curiosity. 
• Lack of clarity or inconsistencies around tasks, protocols, or procedures.
• Lack of accountability.
• Self-anchoring bias or “group think”
• Lack of resources.
• Inadequate training or professional development.
• Interpersonal or interdepartmental conflicts

Now, let's shift our focus to dysfunctional teams in healthcare. You can all imagine a team or unit that exhibits some of these behaviors. Dysfunctional teams in healthcare often display counterproductive work behaviors, such as gossip, high absenteeism, disengagement, a blase attitude, resistance to change, groupthink, and a blame culture. They operate from a place of judgment rather than curiosity. For instance, a statement reflecting a judgmental attitude would be, "Did you see the way she tried to do that IV? Of course, she missed. She always misses."

On the other hand, approaching the situation with curiosity would involve saying, "I wonder why she struggles with this IV. Is there a particular tool she is using that is not beneficial for her, or is it her hand movements? I should find a way to support her and help her improve." While the previous example is from a nursing perspective, the same principle applies to respiratory therapists. Instead of judging why someone has not finished their first rounds, approaching it with curiosity might involve wondering if something happened that requires support, such as an issue with a patient, their family, or another staff member. We can foster a more positive and productive environment by shifting from a judgmental mindset to one of curiosity.

Dysfunctional teams in healthcare often arise due to a need for clarity or consistency in tasks, protocols, and procedures. When there is confusion or inequality in how things are done, mistrust and injustice can develop. Questions like, "Why do we have to do it this way when Blah Blah Blah does it differently?" create uncertainty and erode trust. Additionally, a lack of accountability contributes to team dysfunction. When no one takes responsibility, or it is unclear who is accountable for certain tasks, it becomes challenging to work effectively.

Self-anchoring bias, also known as status quo bias or groupthink, can further perpetuate dysfunction in teams. Accepting problems or dysfunctions as normal rather than actively seeking solutions or change is a common trap. Anchoring ourselves to the belief that healthcare dysfunction is how things are, prevents us from actively addressing and improving the situation. Inadequate or limited human capital or equipment resources significantly impact team functionality. It would be impossible to dig a moat with beach shovels in a day, and proper equipment is essential for performing our jobs accurately, effectively, and safely. Likewise, no single person can effectively care for an entire unit. Insufficient staffing and resources create challenges and dysfunction within teams.

Similarly, when there is a lack of training or professional development opportunities, it contributes to team dysfunction. It is concerning when hospitals expect employees to know everything within a few shifts, especially considering the limited resources available for training. Adequate training is vital for the functional performance of the team.

Interpersonal and interdepartmental conflicts also contribute to team dysfunction, as they create mistrust and division. Rather than being torn apart by conflicts, teams should strive to work together cohesively. Ironically, conflicts often arise during patient transfers between departments such as the ER and ICU or ICU and OR. Managing these situations differently and seeking more effective solutions can minimize or even resolve conflicts.
Addressing these dysfunctions and striving for functional teamwork is crucial in providing high-quality care and fostering a positive work environment in healthcare settings.

Navigating Around the Noise (cont'd)

• Define your objective
• Manage emotions attitudes.
• Professional direct communication. 
• Understand your impact purpose.
• Respect the position.
• Document effectively. 
• Encourage others to participate empower them through the process.
• Speak up to enhance safety measures. 
• Focus on “what's right” versus “who's right”

To navigate around the noise of a dysfunctional team, there are several strategies we can employ. First and foremost, we must define our personal objectives and encourage the team to define them. This clarity of purpose helps us shift our focus from drowning in the problems to navigating around the noise.

Managing our emotions and attitudes is crucial. Our emotions are our number one superpower, and the most powerful move we can make is not to allow someone else to impact those emotions. Refusing to be bothered by someone's attempts to trigger intense emotions or attitudes is a significant gut punch to their intentions. One approach, as suggested by a Harvard executive coach, is to respond to disrespectful behavior by asking the person, "Are you okay? Is everything all right?" This redirects the interaction and allows us to maintain our composure.

Direct and professional communication is key to navigating dysfunctional team environments. We should clearly communicate our needs, expectations, and advocate for ourselves, our patients, and other staff members. Understanding our impact and purpose helps us maintain focus. For example, we can enter a shift with goals such as making patients or families feel safe, completing rounds thoroughly, or supporting other staff members. While we may not have to get along with every individual, we can still respect their impact on the patient's well-being.

Effective documentation remains important. If we have communicated a concern professionally and directly, documenting it ensures the issue is recorded and allows further action if necessary. Encouraging others to participate and empowering them through the process is also essential. We should promote a culture where people feel comfortable speaking up and honoring their impact on patient care.

In navigating dysfunctional teams, we should focus on doing what is right rather than insisting on being right. The focus should be on the best outcomes for patients, their families, and the team as a whole. Additionally, it is important to be aware of behavior contingent theory. This theory suggests that behaviors become a sense of normalcy as a way for individuals to adapt and adjust. Whether superficial or deeply emotional behaviors, we must acknowledge and create awareness around them. We can work towards a healthier and more functional team environment by adapting, adjusting, and fostering change.

Steps to Enhance Teams 

To enhance our team, we must avoid gossiping and badmouthing others. Having a best friend at work can sometimes lead to counterproductive behavior, such as engaging in gossip. Instead, we should focus on cultivating allies—people we trust and can work with cohesively. These allies become our support system for creating systematic change and promoting teamwork through collaboration, resource sharing, and professional development.
It is important to stop making excuses for toxic people or behaviors. While we may find certain individuals charismatic or entertaining, we must recognize if their actions are toxic or detrimental to patient care or the work culture. We need to prioritize patient safety and the team's well-being over personal preferences.

Encouraging effective communication, trust, and cohesion is crucial for fostering the power of the team. This includes bolstering psychological safety, which is built upon a foundation of trust, advocacy, and empowerment. Clearly communicating team members' roles and priorities is vital. Utilizing opportunities for communication, such as riding in an elevator with a nurse or another care team member, can be beneficial. Taking the time to discuss plans, coordinate actions, and address concerns helps create a smoother workflow and reduces misunderstandings. For example, in a high-risk delivery situation, communicating with the nurse about intubation plans, medication administration, and areas of focus fosters teamwork and clarity.

We should cultivate work relationships rather than seeking best friends. Even if we have personal conflicts or negative feelings towards a coworker, finding ways to communicate effectively and work together towards the common goal is essential. Emotions or attitudes stirred by others should not distract us from maintaining professionalism and effective collaboration.
Following these steps can enhance our team dynamics and create a more positive and functional work environment.

Help Retain & Train 

To drive the needed changes, it is important to be direct in addressing issues related to policies, procedures, best practices, safety regulations, and roles and responsibilities. Clear communication lines should be established to ensure everyone is on the same page. This may involve being persistent and proactive, such as emailing the manager, copying the director and HR, and following up on important matters. We create an environment that supports staff retention and training by taking these actions.

Understanding team dynamics and actively promoting communication, trust, and advocacy are essential. Emphasizing a sense of curiosity and offering support to help others improve fosters a learning and adaptable environment. Building trust is crucial as it encourages individuals to be humble and open about areas of growth. It also creates a safe space where beneficial feedback can be provided and received, focusing on performance and effectiveness rather than seeking validation.

Rather than seeking a best friend at work, investing in building working relationships and finding allies is more productive. This involves valuing and supporting the talent within the team and engaging in direct, curious, and compassionate conversations. Instead of ostracizing new hires, efforts should be made to provide them with the necessary training, development opportunities, resources, and information. By investing in their growth, they can positively impact patients, and there is a higher likelihood of retaining them within the organization.
By taking these steps, we create a culture of continuous improvement, collaboration, and support within the team, ultimately enhancing the overall performance and effectiveness of the healthcare environment.

Soft Skills to Build Success

• Emotional intelligence
• Communication
• Documentation
• Feedback
• Conflict Resolution – What, what, What now
• Interpersonal – Power of perspective  
• Leadership  
• Adaptability
• Resilience

Personal soft skills play a significant role in building success. Emotional intelligence, for example, involves understanding the impact of our emotions on others and how others' emotions can affect us. It requires the skills and intelligence to navigate these emotional dynamics while maintaining control and regulating our own emotions, especially in high-emotion occupations.
Effective, professional, and direct communication is another vital soft skill for success. The ability to communicate clearly and assertively fosters understanding and collaboration. Powerful documentation is also important, as it ensures that information is recorded accurately and meaningfully.

Providing meaningful feedback and practicing conflict resolution are additional soft skills contributing to success. The "what now" method by Dr. Dudley E. Floyd is a useful approach to conflict resolution. It involves identifying the issue, understanding its significance, and determining the next steps or solutions to address the issue.
Interpersonal skills are crucial for building success. Recognizing the power of perspective allows us to transform how we see things and approach challenges. Understanding that we have control over our responses, reactions, and preparations enables us to navigate difficult situations more effectively.

Developing leadership capabilities is also important. This includes being adaptable and able to go with the flow, which is a skill often honed by respiratory therapists who regularly face dynamic and unpredictable situations. Resilience is another key attribute to cultivate, enabling us to bounce back from challenges and setbacks.
Developing tactful insubordination can be beneficial in challenging work environments where dysfunction and toxicity prevail. This involves finding strategic ways to navigate such environments while advocating for necessary changes and improvements. Focusing on these soft skills can enhance our effectiveness, contribute to a positive work environment, and build a foundation for success in our careers.

Tactful Insubordination

• Smoky room experiment. 
• Acknowledge your status quo bias. 
• Focus on doing what is right. 
• Create noise, even when they don’t want to listen. 
• Document - Remove people feelings. State facts, situations, impact. 
• Know the policy, procedures & state healthcare laws.
• Be honest in surveys.
• Provide leadership or team feedback. 

Tactful insubordination is a way of remaining professional while advocating for change. It means not conforming to the status quo bias, groupthink, or blame culture that may exist in healthcare settings. Instead, it involves professionally and directly advocating for necessary changes and improvements.

Acknowledging the smoking room experiment, where individuals often mute themselves out of fear or expectation that someone else will take action, we recognize the need to challenge the palpable status quo bias in healthcare. Unacceptable behaviors from staff, patients, or the organization itself should no longer be tolerated. Examples include denying restroom breaks for extended periods, not providing lunch breaks within 12 hours, or tolerating an abusive work environment. We must focus on doing what is right, even if it means going against the grain, in order to reduce moral injuries.

Creating noise and documenting situations without relying on personal feelings is crucial. We can assert our position effectively by stating facts, impacting and referring to policies, procedures, and state healthcare laws. When participating in surveys, it is important, to be honest and truthful, rather than giving all top ratings simply because a director requested it. If there is any fear of retaliation, it is wise to keep printed copies of emails and evidence of past expressions to protect oneself.

When asked or prompted for feedback from leadership teams, we should provide it in a way that aligns with what is right rather than who is right. By focusing on constructive feedback that aims to improve the organization, we can contribute to positive changes and a healthier work environment.
In summary, tactful insubordination involves advocating for change while maintaining professionalism. It requires challenging the status quo, being honest in documentation and surveys, and providing feedback to leadership teams in a way that promotes what is right. We can work towards a more positive and impactful healthcare environment by taking these actions.

Advancing in Respiratory Therapy

• Find define your passion.
• Advance your skills share those resources.
• Take advantage of educational assistance.
• Explore in-hospital growth opportunities.
• Explore life-science industry opportunities.
• Data science, compliance, regulations, medical & clinical affairs, medical & clinical liaisons.
• Employment services.
• Telehealth (limited)

When considering a career in respiratory, it is important to recognize that advancing in the field only sometimes means staying solely in the clinical setting. To explore career growth opportunities, define your passion and identify what drives you. For example, if your passion lies in advocating for others and ensuring equality, you can pursue avenues within respiratory that allow you to fulfill that passion.
Advancing your skills is crucial for professional growth. If you feel the need to improve your intubation skills, take the initiative to ask for additional training and seek opportunities to enhance your expertise. Once you have acquired new skills, be willing to share your knowledge and resources with others, fostering a collaborative and supportive environment.

Take advantage of any in-hospital education assistance programs available to you. These programs can provide valuable resources and support for furthering your education and career development. Additionally, do not limit your exploration to respiratory-specific opportunities within the hospital. Consider expanding your horizons by exploring other areas, such as data analytics, informatics, or the life science industry. These fields offer diverse career paths that complement your respiratory background and open new avenues for growth and impact. By staying proactive, continually seeking growth opportunities, and being open to exploring different paths, you can expand your career options and make a meaningful impact both within and outside the clinical setting.

• Remember your “why”.
• Organizations ultimately fail when they do not place employees first.
• Be an active part of the solution.
• Set your professional standards.
• You get what you tolerate – set the standard.
• You get what you encourage – this takes time.
• Find ways to ensure leadership works for you.
• Speak boldly!

As you explore opportunities outside the clinical setting, it is important to consider various roles in the life science industry that align with your interests and passion. These roles may include positions in data science, compliance and regulation, medical affairs, clinical affairs, or medical clinical liaison. Keep in mind that many of these positions typically require a Bachelor's degree or higher.
While telehealth is a limited option for respiratory therapists in terms of employment services, it is crucial to remember your initial motivation for choosing respiratory as a career. Reflect on what drew you to clinical healthcare and how it serves your purpose. You can stay aligned with your core values and motivations by honoring that connection.

Recognize that organizations ultimately fail when they do not prioritize their employees. As an active part of the solution, you can set professional standards and establish boundaries. Remember the adage, "You get what you tolerate." By setting high standards and not settling for less, you encourage others to treat you with respect and professionalism. Teaching people how to treat you takes time, but it is worth the effort.
When it comes to leadership, remember to advocate for yourself and ensure that leadership works in your favor. Boldly express your needs, concerns, and aspirations. Your voice matters, and speaking up assertively can contribute to a healthier work environment and better outcomes.

In conclusion, as you navigate your career in respiratory and explore opportunities beyond the clinical setting, stay true to your why, prioritize your well-being, set professional standards, and speak boldly. By doing so, you can shape your career path and contribute to positive change in the healthcare industry.

Questions and Answers

"How do I find ways to work with a manager who is coming from a place of ego?"

Working with a manager who has an ego can be challenging, but there are strategies you can employ to protect yourself and navigate such situations. Documenting your interactions is crucial. Whenever you have a conversation with this manager, follow up with an email summarizing what was discussed and the outcome. This documentation serves as a record and helps ensure that your voice and concerns are heard and acknowledged. In situations where the manager's ego is causing them to become animated or reactive, it's important to remain calm and composed. If the conversation becomes too heated, it can be helpful to suggest taking a break and resuming the discussion at a later time when it can be approached in a more professional manner. After the dialogue, make sure to send a follow-up email to the manager, and if necessary, consider copying HR or your director to bring awareness to the situation.

While it may go against the norm, advocating for yourself in a way that creates effective change is essential if the manager's behavior is creating a negative work environment for you. By taking proactive steps and addressing the issue, you are prioritizing your well-being and promoting a healthier workplace. Managing emotions in a high-stress environment is indeed challenging. It requires developing emotional intelligence and recognizing that your emotional response is within your control. Building the ability to regulate your emotions outwardly, even if you still feel their impact internally, is a powerful skill. Not giving others the reaction they seek, even when you may feel affected, demonstrates resilience and maintains your professional composure. Remember, it is normal to experience emotions in high-stress situations, but having the ability to regulate and manage them effectively is what sets you apart and contributes to your professional growth and success.

How can managers be able to identify dysfunctional culture?

Absolutely, you raise valid points about the challenges faced by clinical managers, especially in respiratory therapy, where they may not be physically present on the floor with the team. As frontline healthcare providers, it becomes crucial for us to effectively communicate with our managers, nursing leads, and advanced care providers to ensure they are aware of the dysfunction happening within units.

By providing them with clear and objective information using the "what, what, what now" method, we can outline the specific issues and their impact on patient care or unit functioning and initiate a conversation about finding solutions. It is important to remove emotions from communication and focus on the facts and the need for improvement. This allows managers to have a clearer understanding of the challenges and take appropriate actions.

Furthermore, we can also collaborate with our managers to address the issues and work towards retaining staff. If we observe new hires being ostracized or facing challenges, we can become their ally and advocate for their integration into the team. By communicating with other staff members, such as respiratory therapists and nurses, and encouraging patience, curiosity, and support for the new hires, we can foster a more inclusive and welcoming environment. Building this allyship and promoting a positive team culture contributes to the growth and success of both individual team members and the overall organization. Effective communication with managers, providing them with clear information about the challenges, and actively working together to address issues can help improve the working environment and support staff retention. Building alliances and advocating for new hires fosters a culture of inclusion and collaboration.

References

Bohns, V. K. (2021). In You have more influence than you think: How we underestimate our power of persuasion and why it matters. essay, W.W. Norton. 

Bridges, W. (2017). Managing transitions making the most of change. Da Capo. 

Chamine, S. (2016). Positive intelligence. Greenleaf Book Group Press. 

Dweck, C. (2016). Mindset: The New Psychology of Success. Random House. 

Herman, T. (2019). The alter ego effect: The power of secret identities to transform your life. Harper Business. 

Kashdan, T. B. (2022). The art of insubordination: How to dissent & defy effectively. Avery, an imprint of Penguin Random House. 

Robbins, S. P., & Judge, T. A. (2018). Essentials of organizational behavior (14th ed.). Pearson. 

Robson, D. (2022). The expectation effect: How your mindset can change your world. Henry Holt and Company. 

Swann, A. (2018). The human workplace: People-centred organizational development. KoganPage.