What Happens When You Work With Warring Tribes?

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My first reaction when asked to write a piece for Injectable Orange was almost embarrassment that someone felt I had something to contribute to this up swell of amazing nursing and medical blogs that have changed the way I think about reflective learning over the last 3 years.  This was quickly followed by an overwhelming feeling of terror – what the hell am I going to say?

After a few weeks of contemplation I decided to take some inspiration from the opening address at the recent SMACCGOLD conference. The incredible Victoria Brazil spoke about the concept of various teams in a hospital being like tribes: the ED tribe, the ICU tribe, the Cardiology tribe, and the various nursing, medical, and allied health tribes. During this presentation a case was laid out detailing perhaps not the best way to navigate through the various tribes of the hospital with their respective cultures and languages to achieve primary coronary angioplasty for a patient presenting with an acute myocardial infarction.

As the laughs and head shaking continued in the audience whilst this case unfolded, in my mind on loop playback was ‘welcome to my daily practice as an ICU Outreach nurse’. I am often asked, ‘what exactly does an ICU Outreach nurse do?’ My response is usually a mixed bag, there is something relating to assessment of the deteriorating patient. I am part of the medical emergency team and to a large degree I am an educator. The one thing I am always sure to explain is that I act as a pivot to ensure the right clinicians are involved in a deteriorating patient’s care to intervene and hopefully change this patient’s clinical course. Another question I am frequently asked in my line of work is ‘how did you manage to get “them” to listen to you when it comes to escalating the care of deteriorating patients?’ This is something I have struggled to answer, but thanks to Victoria’s presentation and a little book called Tribal Leadership, by David Logan, I have come to a better understanding of how I achieve this task. A function which can be so difficult at times. More importantly I have reflected on how I can continue to improve on the vital skill of communicating.

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David Logan describes organisations and subsets within these organisations as a tribe. A tribe as a group of 20 to 150 people who know one another well enough that if they saw each other walking down the street, they would stop and say ‘hello’. I thought about this from a ward perspective It’s the nurses, doctors and allied health teams you work with every day, not the ‘tribe’ that works 2 floors down with a different specialty to your own. It’s the nursing staff, whom see their role completely separate to that of the medical staff.

This book then goes on to describe what makes an effective tribe, culture. This culture is a product of the language people use and the behaviours that accompany those words. The nursing staff don’t suggest interventions, the resident dutifully scribes the notes on rounds but lives by the adage ‘been seen and not heard’, the graduate nurse who is worried about her patient’s respiratory rate of 30 but has been told before that is fine on this ward. So what happens when we need something from another tribe? My medical patient needs a surgical review. The in-charge nurse is justifying a 1:1 nurse ratio for an unwell patient and needs medical documentation, but the medical team don’t agree?  In most cases, it is what I like to call war; different tribes, with different cultures and language at the end of a bed. How do you strive for the common goal, when you are from a different culture and speaking a different language? David Logan describes the five stages of tribal cultures that evolve from individual focused behaviours and language. Tribes who strive to be the best against the competition give way eventually to the tribes that can work with almost anyone to achieve the common goal and compete only with what is possible. Sounding like a hospital near you yet?

These five stages of tribalism gave me the insight to understand that I was able to have effective conversations and escalate care because, before having the conversation, I take the time to think about where the other individual was coming from. I pause to consider whether they are an intern that had been sent by the registrar with orders to ‘sort it out’, but whatever you do don’t bring the patient back to ‘my ward’. Are they the ward charge nurse, that has just been pushed to take three patients from the emergency department under the threat of the 4hr Rule and I was asking her to make a bed for the fourth sick patient. I have taken the time during those rare quiet shifts to get to know the tribal chiefs and understand their cultures.

In my role as an ICU Outreach nurse, I realised I had been striving to be a Tribal leader. David Logan describes this as a very personal journey and to get there you must do the “prep work” on yourself first, including:

  • Learn the language and customs of all five cultural stages.
  • Listen for which tribal members speak which language – in essence, who is at what stage?
  • Move yourself forward, start talking a different language and shifting the structure of relationships around you.
  • Take these actions as you upgrade the tribe around you.

There is so much to this concept that lends itself to the way we work as healthcare professionals, the next time you feel like you are going to war, I challenge you to consider the language and culture of the other team, changing yours may just get you to the common goal.

What happens when you work with warring tribes?

I guess I am lucky enough to be bilingual.