Two coronary care units, one winter. Same rota rules, the flu arriving in the same fortnight. About the same number of empty shifts on the board. By February, one unit had lost three nurses to sickness and a fourth to the agency down the road. Its sister was writing incident reports at eleven at night. The other unit had a hard winter too. It bent. It stayed standing.
The review went to the first unit. Of course it did. People had been harmed. There were forms to work through and questions. What had gone wrong with that team?
Nobody went next door to ask how they had managed.
The story that asks nothing of us
We tend to have an answer ready. That team is tougher. A better sister, perhaps. People who just get on with it. The other team? A bit fragile. Difficult to manage. Maybe the wrong mix of people.
I have heard versions of this in every health system I have worked in. Seven now. The wording changes, but the suggestion is much the same: some people can cope and some can’t. It is an explanation you can agree with and then leave the rota exactly as it is.
Red Team Thinking® calls these Lies We Tell Ourselves™. The stories we keep repeating because they make things easier for us to accept. Whether they explain much is another matter. “They’re just more resilient” is a useful one in healthcare. The team that coped gets a compliment. The team that didn’t is left wondering what is wrong with them. And the people making the decisions further up don’t have much to reconsider.
Something I kept seeing in the cath lab
Two patients arrived on the same night with the same artery blocked in the same place. One lost a large amount of heart muscle. The other had some chest pain, a troponin that went up and down, and left hospital days later with most of the heart intact.
Being brave doesn’t explain that difference. Sometimes the collaterals can explain a lot: small bridging vessels that have developed over time, allowing blood to get around narrowings and blockages. When the main vessel closes, there is another way for some blood to reach the muscle.
There wasn’t a moment when anyone said, right, we need to build these now. They developed gradually, in the background. By the time the patient arrives with a blocked artery, having that other supply can make a considerable difference.
It took me a while to connect this with what I was seeing in teams. Longer than I would like to admit.
In Cognitive Oxygen® (COx), we call this carrying capacity. How much stress and complexity can a team manage before people stop thinking together, pull away from each other, or try to control everything? Some of that depends on the individuals. A lot depends on how they work together and what is there to support them before things get difficult.
What was happening next door?
When you look at the ward that held, you usually find ordinary things. Easy to overlook.
A junior nurse could say, “I’m not happy with bed four,” at handover without getting that sigh. You know the one. People sat down together for ten minutes at two o’clock, and someone made sure it still happened when the day was awful. Two senior nurses could disagree in front of everyone without the rest of the shift becoming uncomfortable. The matron picked up the phone. The rota didn’t keep relying on the same two people to stay late.
You wouldn’t necessarily see any of this in a board paper or on BI dashboards. But people relied on it.
The other unit had good people too. Some of the best I knew. But everything went through the sister. Decisions, difficulties, things others could have sorted. Her signature was needed. And there had never been enough breathing space to develop another way of working. When she couldn’t carry any more, there wasn’t much else to fall back on.
We still go back to the team that struggled
We have systems for investigating harm, and we need them. There is a place to record what went wrong. There is much less space for noticing the problem that never developed because somebody spoke up at handover. Erik Hollnagel has spent years asking us to pay attention to ordinary work that goes well. Most of us recognise the point. Then the next incident needs reviewing, and that is where our attention goes.
Sometimes one person does cause damage. A bully. A leader who has stopped treating people with respect. I don’t want to explain that away by talking about systems. It needs addressing directly. But I would still want to know how they were allowed to have that much influence, for that long, with so little around them to challenge it.
When a team struggles, I think we need to catch ourselves before we ask, “What’s wrong with them?” What did the team next door have that they didn’t? When did it develop? We may have to look back a while. At who had time to meet, how the rota worked, whose concerns were heard. At decisions made by people who weren’t there during the difficult shift. That is a less comfortable conversation. It also gives us something we might change.
And the quieter months matter here. If we get any. They are often when we start wondering whether we really need the team meeting. Nothing urgent today, shall we cancel? The ten minutes together slip. The second senior nurse is needed somewhere busier. I can understand each decision, individually. There is always somewhere else that needs help. But come January, we may be asking people to cope without things they had quietly depended on.
Perhaps some of what we call resilience is support we hadn’t bothered to notice.
This week, find a team that held. Ask what helped. They may not think to mention the ordinary things.