Three Nurses and a Doctor Go Sailing – Some Notes on Communication Style

Untitled from the series, Pareidolia. Charcoal and graphite on paper,
12″ x 9,” by julianna paradisi

There’s an old joke about the personality differences among nurses of different specialties. It goes like this:

A medical–surgical nurse, an ICU nurse, an ER nurse, and a doctor go sailing. The doctor stands at the bow of the boat and shouts to the nurses, “Trim the sail!”

The med–surg nurse asks, “How do you want it?”

The ICU nurse replies, “I’ll trim, okay. But I’m doing it my way.”

The ER nurse shouts back at the doctor, “Trim the sail yourself!”

ICU style. The joke is a generalization, of course. However, I was a pediatric intensive care nurse once upon a time, and I have to admit that the ICU nurse characterization resonates with my own experience. Like the nurse in the joke, I always have an opinion, and rarely mind sharing it. In the ICU, if another nurse, a physician, a pharmacist, or respiratory therapist didn’t agree, conversation ensued. My colleague, equally opinionated, would state her or his position. Data was consulted, and then, more often than not, consensus occurred.

And I often learned something from sharing information. It made me a better nurse. I learned to dig in on a position only if patient safety or my license was at risk. Everything else was pretty much negotiable, face-to-face. From this perspective, our ICU team was similar to a marriage—it would have been unrealistic to expect there would never be disagreement within our team. In fact, if there was never disagreement, someone probably wasn’t being honest about her or his feelings—an approach that can lead to passive-aggressive behavior.

I don’t know if it’s because I no longer work in ICU, or if nursing culture in general has changed, but lately I’ve noticed some confusion about the difference between open, honest communication and bullying. There’s a difference.

Intensity plays a role in this confusion. For ICU nurses, intensity is a learned form of acceptable communication. Likewise, ER nurses are sometimes considered abrupt by other nurses. They’re busy, and need concise, specific information from colleagues presenting a patient so they can quickly triage (prioritize) the need for care. If a nurse is unfamiliar with this communication style, she or he may find giving report to an ER nurse to be very intimidating.

From my ICU background, I know that the best strategy for dealing with this challenge is not to write up the ER nurse for seeming mean and impatient, but instead to give report in a way that clearly emphasizes the assessment leading to the ER admission. This diffuses the problem in the first place rather than turning the focus to the nurse’s personality or communication style. Some nurses call this enabling behavior. I mostly call it being a team player for the benefit of my patient—the reason I am a nurse.

In contrast, bullying behavior leads neither to more focused communication between nurses or to better patient care. The communication of bullies is punctuated with insulting tones of voice and eye rolling. Bullying communication is meant to ridicule and demean the receiver. There is no benefit for the patient, and it can actually put patient safety at risk.

What set me thinking about this subject was a conversation with a friend whose student didn’t seem fully engaged in the learning process. Several preceptors had complained about the student, but before the student’s final evaluation could be completed, the hospital’s legal team had been consulted to determine whether giving the student low marks, even in the presence of objective data, could in any manner be interpreted as a violation of the hospital’s harassment policy.

I laughed, remembering a preceptor-training workshop in which a participant role-played the preceptor and a trainer played the part of a newly hired orientee, while someone else played an ICU patient family member. The “orientee” made first contact with the “family member,” wreaking havoc by carelessly handling lines and not knowing the patient’s diagnosis, prognosis, allergies, or even name. In response, the family member became totally unglued, berating both the orientee and the preceptor, who stood by speechless because the orientee’s terrible performance had been so over-the-top.

What happened next had surprised me. The preceptor/participant and her orientee were placed in front of the class to “debrief” the situation described above. The preceptor/participant sat facing the wayward “orientee,” with open body language, arms and legs uncrossed, a neutral facial expression. She seemed poised and fully present. With a smile, eye contact (and no eye-rolling), and a little humor in her voice, she began the conversation, “Well, that didn’t go very well, did it?”

The workshop came to a grinding halt as the other participants protested the insensitive manner in which they felt the preceptor had addressed the “orientee.” They wanted her to be more touchy-feely: “Are you okay? How do you feel?”

I disagreed with their criticism. I felt the preceptor had used humor and frankness to cut through the drama of a situation that everyone already knew hadn’t gone very well. Rather than ignoring the elephant in the room, she’d opened the door for conversation. If the “orientee” had legitimate explanations for not covering the basics of patient care (taught in nursing school) before entering the patient’s room, she had an opportunity to explain. Perhaps her child was ill, requiring her to find a last-minute babysitter. Maybe her car wouldn’t start, and she’d been late. Or the call light had gone off and she’d entered the room without time to prepare. Something, anyway. Together, the preceptor and orientee could then formulate a plan to do better next time.

However, I’m an old ICU nurse. I can be intense.

What was not addressed in the workshop was the most realistic feature of the entire scenario—that the preceptor/participant had had no time to process the situation and deal with her own feelings before having to discuss it with her orientee. As I saw it, this lack of time contributed to the preceptor’s direct approach. Precepting does not occur in a simulated skills lab. It happens in real time, during high-acuity patient care. The preceptor/orientee team works under stress. If more touchy-feely communication is expected, this expectation needs to be factored into staffing and assignments, not heaped onto the burden of an already too heavy workload.