The hierarchy must be healthy to achieve critical outcomes in patient safety, patient experience, workforce health and wellbeing, and cost-effectiveness.

In a healthy hierarchy, staff must have the right skills, education, and experience to direct and carry out clinical and care-related tasks. Clear lines of communication, roles and responsibilities, policies and protocols, and scope of practice are all important. We can think of such things in terms of the structure. We should also consider the hierarchy in terms of process! This refers to how clinical and care decision-making is informed and carried out by the people involved. It is the more flexible part of a hierarchy that involves communication, relationships, teamwork, and culture. In order to appreciate this idea, we can examine three process-related traits that are prevalent in a healthy hierarchy.

1. Staff are skilled in giving and receiving constructive feedback and supported by the culture. In a thriving hierarchy, feedback is fuel for teaching and learning. Staff at all levels are in a dynamic dance of exchanging experience, knowledge, and skills. Mistakes or problems are opportunities for individuals and teams to grow personally and professionally and improve outcomes.

Leaders prioritize ensuring effective feedback training is provided, and the expectation for practice is clear to everyone. Guidelines for giving and receiving constructive feedback are fairly straightforward, but without a culture where people feel safe to speak up and willing to listen, the practice is hard, if not impossible, to maintain. Pervasive bullying or blaming can shut down even the most emotionally intelligent and assertive professionals.

From a communication standpoint, it is worth noting that giving constructive feedback is an assertiveness skill, and receiving it is a listening skill. Both require emotional intelligence, such as self-awareness, confidence, empathy, and perspective-taking!

2. Everyone has the capacity to lead and follow. In a thriving hierarchy, everyone on any team or in any position will have the capacity to lead and follow. Like feedback, both involve listening and speaking up skills and a supportive culture. In such a culture, everyone feels respected, safe, and accountable for speaking up.

Historically, the health care hierarchy has been a top-down structure that predominated military and medical models of the 20th century. Here, doctors give orders to nurses and other professionals; nurses and others follow them, and they give orders to paraprofessionals. A process that, generally speaking, makes sense from a clinical standpoint as those with more knowledge, skills, and experience direct the decision-making process. It isn’t foolproof, though, because the people at the top of the hierarchy are not always the ones with vital decision-making input to share. When there are toxic issues involving status, power, or ego among people or within the culture, this more collaborative element of communication is hindered. And sometimes, with catastrophic results!

Some of the most sophisticated physician and nurse leaders I have seen in action are able to direct care and build a culture of trust where everyone is respected. With grace and clarity, such leaders move from authoritative to collaborative leadership styles and back in real-time. It is also impressive to see courageous support staff such as nurse assistants or housekeepers jump into a leadership role with vital input at any given moment. Such fluctuations in leading and following are incredible to watch, enriching for everyone, and so much safer in terms of care. The more we cultivate these skills in everyone, the better our outcomes will be!

Imagine the code team in a hospital, where the physician arrives on the scene and gives orders while the team follows them. In these same moments, input from everyone around speaks up if they see or know something important.

Housekeeper: Watch out there is a puddle of something on the floor there.
Nurse: Wait, this patient has an allergy to amiodarone!
Social worker: Hold on, the DPOA for medical care just signed a DNR.

In the dynamic, fast-paced, high-stakes world of health care, things are changing all the time!

3. Respect, trust, and dignity are in the air. Respect, trust, and dignity are hard to measure and difficult to teach. Yet we all know what they look, feel, and sound like. When these ideals are present, people are busy, yet there is a sense of overall camaraderie and interdependence. Leadership and teamwork are amazing, and teaching and learning are ongoing processes.

Patients see how people treat each other and are more likely to feel (and be) cared for by the entire team! Work is more rewarding and mistakes and burnout; less likely.

Alternatively, disrespect, distrust, or indignity plague toxic cultures. They breed bullying or blaming, which many of us are familiar with, and all of our outcomes suffer.

How medical improv helps: Promoting positive process

As you read these traits, you might be wondering how on earth we can cultivate such behaviors. How can individuals develop abilities for showing ownership, apologizing, speaking up, leading, following, appreciating other perspectives, forgiving oneself and others, and similar behavior? They represent such challenging social and emotional development, and they are practices that probably won’t be sustainable for long in a culture of bullying and/or blaming.

Unless there is an influx of individuals with these competencies or an intervention that promotes them collectively, shifting the hierarchy and culture to one where respectful interactions are supported becomes possible. Then, there will be a ripple effect—a very positive one.

Medical improv is an effective intervention because experiential activities when facilitated properly, become tools that build the ‘soft’ skills that promote positive relationships and effective communication. Competencies that contribute to healthy teamwork, hierarchy, and culture. All of which will, in turn, support practicing the skills. Medical improv tools are based on a “YES AND” philosophy where MANY experiential activities can be used to help accomplish all of these objectives.

I’ve been researching, teaching, and writing about communication-related skills and health care outcomes for over twenty years, integrating experiential activities from the world of improv for about fifteen of them. Improv is, without a doubt, the most effective and engaging modality I know of!

Beth Boynton is a nurse consultant.