Family Systems and Health, 35(1), Mar 2017,70-76

Carlos E. Sluzki

IN SEARCH OF A NEW IDENTITY:
AN INSTITUTIONAL CONSULTATION AT A SUB-ACUTE INPATIENT UNIT IN A GENERAL HOSPITAL

ABSTRACT

An institutional consultation was conducted by the author at a Sub Acute Inpatient Unit of a general hospital, requested due to profound malaise in its personnel. The process of the consultation and the narrative shift that was anchored by some procedural changes led to a remarkable improvement in the daily experiences of the staff. A subsequent discussion of traits of this intervention allows offering some guidelines about institutional consultations and change.

INTRODUCTION

The descriptive name of a functional unit in any organization may imply the activity carried out by its personnel. However, it does not guarantee members’ emotional affiliation or professional fulfillment.

Collective identity, group mystique, and emotional affiliation require additional ingredients. They include, among others, (a) meaningfulness of the task at hand as depicted by its name, mission and vision; (b) vicissitudes of the history of the group since its inception; (c) a golden ratio between authority, that is, some degree of decision-making power, and responsibility in its personnel, namely, the potential positive and negative effects of a person’s action – authority without responsibility fosters bureaucracy while responsibility without authority fosters higher levels of task-related stress; (d) the differentiated nature of their collective job – being part of a sophisticated problem-solving team in a factory will tend to be associated to an enhanced emotional affiliation of its members than being part of an assembly plant; (e) sense of the value of the tasks at hand – working as a team at a nuclear facility’s risk-control unit, especially if responsibilities and decision-making process are shared, will tend to be more gratifying, regardless of the risks and potential stress, than being a member of a grounds cleanup crew of that facility; and (f) survival value of the affiliation – it is more viable and, in fact, necessary to enhance the affiliation and cohesion of a military platoon (the “band of brothers”) than of field workers in a large harvest.

These general considerations apply indeed to hospitals, organizations with practices that are critical for a smooth articulation of its components, while adapting to environmental and technical changes taking place at an amazing pace. They are impacted by advances in health care, incorporation of new technologies – some becoming a necessity almost overnight because of their effectiveness while astronomically expensive to adopt and costly to amortize – new demands that are in turn the result of those advances as well as general improvements in public health and in customers education, new restrictions imposed by managed care intermediaries, and new policies of austerity in health care motivated by escalating costs. As a result of those forces, hospitals struggle continuously between stability and change, and so does its personnel. This struggle became clear during a consultation that I conducted at a general hospital during a period of distress displayed by the personnel of a sub-acute unit.

THE SETTING

I received a request of the administration of a regional hospital to provide a consultation to a sector in turmoil: Their recently created model Sub-Acute Unit (SAU) had an unusual number of nurses expressing dissatisfaction with their job, requests of transfer to another units and with a telling high absenteeism.

This well-established suburban general hospital in the mid-West, a not-for-profit entity with a teaching affiliation to a medical school and a broad continuum of medical specialties, was the dominant health resource and source of employment in that county.

The SAU focus of the consultation was a step-down intermediary facility created less than a year before this consultation. It was dedicated to patients dependent for their survival on intensive care and high-tech equipment – including a substantial number of patients dependent on medical ventilators via tracheotomy – but not in a life-and-death crisis. Most of these patients had been previously at the hospital’s very busy Intensive Care Unit (ICU), from which they were transferred once an immediate health crisis was averted. That new unit increased the bed availability at the ICU, until then was frequently full and forced to refer out many patients in need of intensive care.

The ICU served, as expected, the usual range of acute medical emergencies, including recent cardiovascular and cerebrovascular accidents, major traumatic injuries, multi-organs decompensation, and patients exiting from major surgical procedures. In turn, the SAU received many of those patients once stabilized at the ICU, and was defined as an intermediate station toward transfer to a general hospital bed, a rehabilitation center or back home.

THE PARTICIPANTS

I started my consultation with a conversation with the hospital administrative director, a friendly African-American man who had requested the consultation, the rather low-key SAU intensivist medical director, and the friendly SAU head nurse, both White woman. The conversations were informative and useful. They were all rather disconcerted by the malaise at the unit, as they couldn’t explain it, and gave me carte blanche to proceed with my task.

To further my understanding of the context and nature of the problem, I then met separately with the head nurse – who in fact was the one who had triggered the requested for the consultation.

As I was informed in those meetings (and corroborated in subsequent conversations with the staff), the salary of the SAU and ICU personnel was similar, and its level was at par with the overall market. In fact, neither salary nor scheduling turned up being an issue. I also explored potential issues regarding race, gender, or sexual orientation – none were described or brought to my attention explicitly or implicitly by the staff. The rather low-key SAU medical director seemed to delegate all personnel issues to the Head Nurse. Both medical director and head nurse seemed to be liked by the administration as well as by the staff. The nursing staff was predominantly female and with a balanced ratio of African-American, Philippine and White extraction. No complain had been lodged by any of them about discrimination or inappropriate behavior by other personnel. The facility proper was modern, with a footprint of the unit that fitted the tasks at hand, and was well lighted and appropriately furnished. Again, the reasons for the unit’s malaise, which contrasted with other units at the hospital, escaped them.

I subsequently met collectively with her and two of the three shifts of SAU nurses. I explained my presence, defined my role as neutral consultant, and invited their collaboration. My presence was welcome by the majority, while met with healthy ambivalence by some.

Most of the SAU nurses had a prior experience at the ICU. They were, therefore, nurses with special training and competence in the management of critically ill patients as well as of the increasingly complex medical equipment used to monitor vital functions and to compensate for failing physiological functions, including, of course, defibrillators and medical ventilators via intubation, tracheotomy or tight mask, not to mention “code blues” and other emergencies.

Exploring informally their experience in the unit, most of the SAU nurses expressed dissatisfaction with their job in a variety of ways: “It is boring”, “Patients are nasty, demanding and mistreating the staff”, “Its not a gratifying experience”, “There is no sprit de corps”, and so on. Most would have liked to stay at or be transferred back to the ICU, or even to a “regular” inpatient unit.

DATA GATHERING

Prior authorization by the respective medical and nursing directors, I also spent a few hours “visiting” the ICU as well as the SAU units. In this task I was both a systemic observer and an ethnomethodologist, elucidating patterns and observing as well as chatting with staff to reconstruct their view of within – and between – units social climate and processes.

At the ICU most patients were either unconscious or semi-conscious, and the atmosphere was populated with equipment-generated sounds, the staff responding quickly and efficiently to any sign of deviation of parameters. There was a “do or die” intensity, marked by frequent triumphs and occasional dramas. At he end of the day, hospital-based physicians, nurses, and the rest of the personnel tended to feel spent but satisfied with their daily battle.

In turn, SAU patients would remain there for longer periods that at the ICU. Most if not all of them were conscious, reasonably oriented, and rather demanding of the staff, who would be busy responding to patients’ as much as to equipment calls. Patients, as well as their families, were more aware than on the ICU about the seriousness of their conditions and able to begin to process their circumstances. Hence, they were anxious to engage the SAU personnel in details about their diagnosis and prognosis, possible complications, and possible treatment alternatives, Nurses frequently experienced them as clingy and demanding. In addition, patients would complain about pain and discomfort. At the end of the day, the nursing staff felt exhausted, a bit abused, and without closure: stories of the day didn’t end with triumph of defeat, but tended to have a nebulous “to be continued.”

In addition to eager to discuss details about their condition, most patients at the SAU unit were medically challenging, requiring care for complex wounds, decubitus ulcers, catheters and stomas. However, one of the pervasive bones of contention had to do with patients with whom the staff had to implement the daily process of helping them to wean from ventilators.

Ventilators, it should be noted, are experienced as a mixed blessing by lucid and semi-lucid patients with respiratory insufficiency. On the one hand, they are life-saving devices that stave off the experience of death by suffocation by patients unable to breath on their own On the other hand, ventilators’ rhythms are externally regulated and do not respond automatically to variations in the blood oxygen saturation. Therefore, their rhythm is not infrequently at odds with what is experienced by patient as their needs and emerging natural reflexes. And, as their health improves, most patients relying on ventilators must, whenever possible, be weaned from their use, so as to activate the normal respiratory muscles, frequently weakened by disease and/or by the use of ventilators (in turn necessary during many severe health crisis.)

This complex scenario comes to light when patients with potential capacity to breathe begin the nurses-monitored routine of minimal but relentless progressive increase of minutes-per-hour-per day of disconnection from ventilators. In most cases, patients undertake this process with reluctance if not with distress: they don't trust their own autonomous breathing capabilities, overrun and almost deactivated by the use of the ventilator. But, to complicate matters, while the subjective experience of hypoxia triggered by respiratory insufficiency is extremely distressing, the difference between physical capability and emotional distress – between actual hypoxia and “dependency” – is difficult to establish both subjectively and objectively. Hence, there was a frequent tug of war between nurses, who wanted to move according to plan: the patient's reluctance contains a component of anticipatory anxiety even before a physical distress could be in place, and is perceived by the nurses as oppositionist, while the patient perceived the nurses as behaving like callous torturers rather than as allies in his recovery process. This confrontation fed a circumstantial point of entry into a larger issue, namely, the lack of a positive identity by the unit. The transformation of that narrative became the main goal of my intervention.

INTERVENTIONS

Each distinct social network – the set of all those members who consider themselves a part of a given functional, social, or ideological aggregate, it being a family, a baseball team, a fishermen club, a platoon, an army, a political party, a soccer team, a given work-based unit such as “the team of the ICU”, in sum, any self-recognizable set – is tied together by a set of practices and of assumptions that holds a mystique of sorts, sometimes explicit (“We are the few, the proud, the Marines”) (“Our family is uniquely connected emotionally”), sometimes fuzzy (“We love our local team because we are locals.”)

Being part of the aggregate “ICU” in that hospital – and in most hospitals – entailed being the holders of a heroic narrative, a mystique of proud doers. In turn – I began to realize – being part of that new SAU enveloped its members inside a tainted narrative of being second-class citizens (the “step-down” label contributed to that¹.) That narrative – as any narrative – was anchored or supported by a series of practices. One of them was, as I discovered, the record keeping method to document the above-mentioned weaning process. This became clear when shadowing a nurse during the routine that preceded, accompanied and followed the minutes-without-ventilator practice. At a given moment, to support her frustration, she showed me the record-keeping graph where she was marking with a dot the number of minutes without ventilator tolerated by that patient in each of the several daily sessions. The x line that connected the dots was almost horizontal, showing the minor advances made by that patient throughout the day. I asked her to show me the daily graphs corresponding to this patient for the past two weeks. Once she pulled them out of the thick chart, I took a blank sheet and drew a graph by compressing the abscissa so that, instead of occupying a full-page per-day, the graph would show the progress made by that patient in two weeks. That graph showed a steady progress in the weaning process, with a steep improvement from day one to that day. The nurse was very amused “at my trick” and at the same time very surprised about the progress that that patient was making. In fact, she showed it to the patient with encouraging enthusiasm. She then showed the new graph to the head nurse, suggesting – half in jest – that this new approach would be a moral buster to the unit. Interestingly, the head nurse brought the issue later to the medical director, who loved the idea and endorsed the change. The graph conversion and its effect became quite quickly a source of animated banter among the staff, alternatively defining it as a way of tricking oneself with statistics and as a new evidence of progress.

In the wake of that circumstantial moment of optimism I asked the head nurse to convene two meeting, one-weak apart, of the whole SAU nursing staff. I started the first one expressing my appreciation for their having made my task a pleasant one. I then offered my “outsider’s view”. I described the SAU as a new unit in search of its identity. I perceived the SAU, I told them, as a space for “re-entry into life” for patients still shaken by their near-death experience, a territory where they patients passed from being mainly objects of care – as they were treated at the ICU, probably for good reasons – into being subjects, which required the more challenging practice of an “integrated, bio-psycho-social medicine.”

The staff expanded this positive description eagerly, commenting that that place in the continuum of care required for them to be more sensitive to idiosyncrasies of the patients, something not always easy to do. From that perspective, one of them said, the mindset required for the ICU was that of a M.A.S.H unit, while the SAU required “a more humanistic role.” Rather than being bothered by the patients insistence on wanting more information about their predicament, said another, talking to them was, or at least should be, part of her role. Those descriptions was echoed by others, and led to an animated discussion of the extent to which this description was challenging in so many aspects. It was clear that my own narrative about the unit was resonating, becoming expanded, and eagerly incorporated by the participants as their own.

The second meeting, a week later, that included the medical director of the unit, started with the theme of the patients on ventilators and of the new graph. I introduced a supportive description of the unavoidable frustration of the staff when dealing with the patients’ reluctance – echoed by several participants – followed by an empathic description of the plight of those patients, including comments on their dampened breathing reflexes, the terror of hypoxia, and their resistance to leave a lifesaving raft to being to swim freely. Both sides of the experience were defined as reasonable while, in fact, they facilitated a vicious cycle of misunderstanding and an adversarial rather than collaborative relationship, when in fact both sides were sharing a common long-term goal. How would a collaborative process take place, I asked. The group, first reluctantly, and then with increasing animation, picked up a timid suggestion by one of them – which I amplified – that the weaning plans should be drawn not only by the medical staff alone but include the patients in its design. One of the nurses added that, in fact, patients’ families should be included more in discharge planning, as they were the ones who would continue the care of the patient at home. Those themes were discussed extensively, drawing the support of all the participants. In closing, one of them associate this approach with thee different message entailed in the modified graft to document patients’ progress toward weaning, again a source of animated comments intertwined with praises.

The “humanization” (using their wording) of these patients and families and of the staff’s own view of the SAU and of themselves was taking hold as a dominant narrative. It was evolving toward a constructive “integrated care” approach, and a sprit de corps was developing among the staff – “we should have a slogan for our unit,” proposed one, half in jest. “We should call ourselves the Back-to-Life Unit”, said another. “Our measure of success will be when one of the ICU nurses requests to be transferred to our Unit,” commented a third one.

At that moment in the conversation I adopted a position of cautionary restraint: “You may end up influencing the way care is provided in the whole hospital, but do it one step at the time and by example!” My rationale for that stance was that one of the potential problems of this build-up of a positive labeling of the unit’s role – the creation of a mythology alternative to the one they had – risked developing an oppositionist, competitive stance with the ICU, constructing them as the negative Other, the “less-than.” I detected that risk in occasional denigrating comments about the ICU staff, such as “They (the ICU staff) have the easy all-or-none, machine-driven first 48-hours, while we (the SAU) have the real nursing job.” The hospital being a system, a change in the quality of process and spirit of the unit will have a hallo effect on others, each one at its own pace, while referred regularly the ICU nurses as “their brethren,” hoping to recruit enough semantic allies to reduce polarization. In turn, the Head Nurse said that she would try and organize a joint meeting of the nurse of both units to enroll them into implement a process of patients transfer between units that would maximize information about the patients emotional status and their families involvement and attitudes. This meeting ended, as the first one did, with an animated conversation that reflected that new budding collective identity.

RESULTS

I had two follow-up meetings with the SAU staff timed one-month apart that included nurses, the by then slightly energized medical director of the unit, and two respiratory technicians. The uplifting spirit and new mystique of the unit was holding: the climate was described as much improved, the bantering about the “new name” for the unit continued whenever any of them made a disheartening comment, and the shift toward a conjoint patient-staff planning for weaning was being implemented. A meeting between the ICU and SAU head nurses had taken place, and an improvement in the information that accompanied the transfer of patients had been agreed (interestingly, that would have a contagion effect, as the ICU staff would also have to pay more attention to psychosocial variables of the patients in their own unit.) And, alas, the new graph had been adopted.

In closing, I met again with the medical director of the unit and also with the upper administration of the hospital, reinforcing my positive description of the unit, and praised the collective awareness and pride about the critical role of the unit in the continuum of care.

In a 6-month telephone follow-up, the SAU head nurse informed me that the collective climate remained cohesive and optimistic, and that the unit had been recognized by the hospital administration with a “top performers and spirit” award, which contributed to firm up their sense of being, and being seen as, valuable.

DISCUSSION

To start with, how did I conduct my inquiry?

• I respected the lines of authority of the organization, through having an initial and a closing meeting its upper echelons – to enlist their legitimization of my presence and their support of (or at least, not opposition to) my task
• I explored with a “not-knowing” stance² the physical and social environment that framed the conflict
• I reconnoitered possible triggers and escalators of the problem, such as overt race or gender biases (beyond the ones embedded in our society), power abuse, negative behaviors of others, differential salaries or perks, etc.
• I facilitated group discussion maintaining a stance of positive connotation and assumptions of good intent
• I explored the constituents’ views and amplified selectively some of them as building blocks of alternative, more constructive view of their unit and of themselves and of the other characters in the narrative, developing in that way a positive mystique about the unit (Sluzki, 1992a & b; Cobb 2013.)
• I explored and facilitated changes in record-keeping and other procedures, assuming that their modification would help to “anchor” the new, more positive narratives of goals, procedures and participants (Cobb, 2013.)
• I kept an eye to prevent the development of a “negative Other” that could foster a climate of confrontation, which may reduce the conflict at hand while creating a new area of conflict

CLOSING COMMENTS

Social reality is constructed through shared narratives. Institutional narratives – the label of a unit, the implied or explicit assumptions about it, its mystique – are omnipresent, and have a strong emotional and pragmatic effect on participants and on their tasks. In fact, their performance will solidify that narrative. At the same time, narratives can be transformed through changes in practices, and, reciprocally, new practices can support new narratives. Needless to say, the more collaborative and organizationally sustainable that transformation, the more the collective satisfaction. In contrast, polarizing and conflictive narratives are built against opposite counter-narrative (good vs. bad, sane vs. insane, and, in this case, idealized ICU and denigrated SAU), a dynamic that entrench conflicts and makes change more difficult.

Institutions – hospitals being a good example – are extremely complex systems, immersed in, and vulnerable to, larger socioeconomic, cultural, scientific and political forces, and therefore in constant change. Internally (how could it be otherwise?), the cogwheels of each of the subsystems components of the system hospital are responsive to those changes and in process of constant re-adaptation and accommodation. As a result of those changes, new goals are established, new missions are created, new collective identities are forged, frequently without even the awareness – and far from a buy-in – of those involved in the daily tasks of keeping these processes operating effectively. This lack of awareness may result in added alienation – in the sense of a distancing between the task and those who carry it – generating a malaise that may acquire, and frequently does, institutional proportions.

Prospectively, the creation of new units in any healthcare organization – and of any new healthcare organization – can be made more effective by the design of mission, vision, tasks, processes and labels that will not only assure an effective and supple system but will seed constructive narratives that in turn allow for a better affiliation of their constituents.

Awareness of these process and collaborative involvement by all parties involved in those changes is the best preventive action (and doing nothing, assuming that staff will somehow manage to accommodate, the best way of assuring discontent). In turn, when organizational shifts create new hurdles and new challenges, a punctual intervention, microcosmic within the institutional macro-cosmos, may open-up ways of restituting pride and meaningfulness to the personnel while improving the system as a whole, as was the case that prompted this consultation.

REFERENCES

Cecchin, G. (1987). Hypothesizing, circularity and neutrality revisited: An invitation to curiosity. Family Process, 26(4): 405 – 413

Cobb, S. (2013): Speaking of Violence: The Politics and Poetics of Narrative in Conflict Resolution. New York, Oxford University Press.

Goulishian H. and Anderson, H (1987): “Language systems and therapy: An evolving idea.” Psychotherapy, 24:529-38

Sluzki, C.E. (1992a): "Transformations: A blueprint for narrative changes in therapy." Family Process, 31(3): 217-230

Sluzki, C.E. (1992b): The better-formed story. Chapter (in Italian) in G. Cecchin and M. Mariotti, (eds.): L'Adolescente e i suoi Sistemi. Rome: Kappa. (pp.37-47) Also discussed in Cobb (2013).

Suzuki, S. (1973): Zen Mind, Beginner's Mind: Informal Talks on Zen Meditation and Practice. Berkeley, CA: Weatherhill

ENDNOTES

1. This is analogous to “first responders” in situations of mass trauma, where the impact of care and resources is very immediate, compared to the slow process of those dealing with infrastructure development or repair, where monthly progress is more appropriate to a sense of accomplishment and group morale.
2. Also known as a position of “curiosity”(Cecchin, 1987), similar to the “beginner’s mind“ of the Buddhist tradition (Suzuki, 1973), actualized for the narrative literature by Goulishian and Anderson (1987.)