Saturday, December 29, 2007

I Pity The Fool: A Team versus B Team

Movin' Meat has a post up from a week or so ago about what it's like to work with the B Team of nurses.

It got me thinking about the differences between the B and A teams. I've been travelling a lot this past month to different units as staffing gets and stays wonky, and I've definitely had to adjust to the B teams on my own and other units. (Everybody thinks they're on the A team, but I think perhaps I'm not too far off-base with my thinking.) Some of the differences I've noticed:

1. With the B Team, shit simply does not get done.

Illustration: Two weeks ago I floated to another unit. Two hours prior to shift change, one of the day nurses had called in, and the night charge had not called anyone else to try to fill the spot. That's the charge's responsibility, working in tandem with staffing, at our facility. So I showed up, the floor was short-staffed as hell, and we all started with eight high-acuity med/surg patients.

Illustration Numero Dos: While on yet another unit, I got report on a postop patient who had a hemoglobin of 6 and a crit of 24, a blood pressure of 80/48, and a temp of 94.3F. The reporting nurse said, "You'll have to run two units of blood, stat." Uh, no, I replied, since the patient doesn't meet transfer criteria; you'll have to be the one running the blood. "But this guy's been down here four hours already, and I have two more patients coming in!" was the reply. (crickets...crickets) Quick cluebat: If you're postopping a patient for four hours, and he's your only patient during that time, and he's not stable, you have time to run blood. No, really. You do. Trust me.

Illustration Number C, or How It Should Be Done (The A Team): One week postop, a guy who'd had a radical prostatectomy showed up on the floor hemorrhaging from his penis, sweaty, with a temp of 95, HR 126, BP 90/50. By the time the resident had been able to cut out of surgery (half an hour later), I had drawn a rainbow of labs, typed and crossed two units of blood, started a saline bolus, administered a total of twelve milligrams of morphine for his excruciating pain, and started two large-bore IVs. I had a coudet cath set and urinometer at the bedside, along with dilators and lidocaine jelly and Versed.

I could not have done this all myself; the other nurses on the floor did things like start one IV while I did another, called the blood bank to give 'em the heads-up on the patient, and ran supplies back to the room. *That's* the A Team for you.

2. Attitude is everything. With the B Team, the attitudes suck.

Illustration: B Team tech/unit secretary/charge/staff nurse comes in, snaps the heads off co-workers, throws tantrums at the lab and radiology staff, belittles the respiratory therapists, and refuses to provide lift help. She or he spends most of the day on personal phone calls and surfing the Web. There's always a personal crisis that either takes up hours of the workday or necessitates the person leaving early. Best example? A secretary I'm fortunate enough not to work with all that often walked in and announced she'd have to leave mid-morning to attend the funeral of a relative, shot during a bungled drug deal.

How It Should Be Done (The A Team): Everybody on the unit shows up on time, clean, not hung over. Perhaps without the shiny-happy attitude that characterizes Disney employees who are still on the clock, true, but with coffee in hand and ready to work. Personal disputes are relegated to the back burner for twelve hours and cell phones are on vibrate. "Cute Overload" is checked for therapeutic reasons only. This is, thank God, where I work.

3. That certain indefinable something: The B Team Ain't Got It.

I don't know if it's experience (though newbies can certainly be A-Teamers) or perceptiveness or initiative or what, but the A-Team has something the B-Team ain't got. You'll notice that there are some nurses who rarely have patients go bad, unless circumstances are extreme. Some nurses seem always to be a step ahead of the docs when it comes to changes in their patients' conditions. Some nurses rarely if ever have patients who end up with decubitus ulcers or constipated. Those are A team nurses.

4. Humility and the ability to admit when you're in the weeds: See Above.

I work with really, really good people. Therefore, when I'm totally rag-assed and overwhelmed, I can ask for help. When any one of us doesn't remember what the hell a lipase value means or what a particular surgery involves, we ask about it, and nobody laughs. If somebody's in a bind with some procedure or other, or doesn't remember exactly how to level a ventriculostomy, we all are willing to help. And we're not afraid, any of us, to admit that there's somebody better at starting IVs or running NG tubes or putting in a catheter.

God help the nurse who works with the B team: she's on her own.

5. Finally, professionalism and calm: Not To Be Found on the B Floor.

Illustration: Fed-up attending throws temper tantrum at nurses' station. Charge nurse responds by getting in his face. Situation escalates. Nasty words fly. People start waving their arms around. Security is called to de-escalate the fight. (Yes, I've had a fun month, thanks for asking.)

How It's Done On the A Team: Fed-up attending throws tantrum at nurses' station. All the nurses stand around watching until he runs out of steam, then charge nurse remarks calmly that she's glad Attending feels the same way we all do, and why doesn't he write an email to the Carpeted People about it, since our complaints haven't made any difference? She then shows him how to operate the email system and thanks him for his concern. No longer fed-up, the Now Abashed Attending apologizes for his behavior. We accept the apology as a group and all go on taking care of business.

No screaming, no freaking out, no security, and everybody involved understands how professionalism was breached, how it was restored, and where we all stand individually and as a group. We're working together rather than at odds with each other.

Even A teams have B days, for sure. Sometimes everybody's a mess, or getting sick, or a mess *and* getting sick. The A teams, though, pull out of the weeds and keep going, while the B team floors fall to hell. I'm lucky enough to have landed on the A-est of the A-teams at our facility, and fortunate to be able to keep up with my coworkers. After the last few weeks, I am not going anywhere else. Ever. Period.

That's the kind of loyalty the A team inspires.


TravelingNurse said...

Perfect examples, I see it everyday and you can tell which team is on when you walk on the unit. As a traveler life is much easier on the A team, and I think you can tell as well if your traveler or agency nurse will be on the A or the B team within the first hour of the shift. May you always be blessed with your A team members!

Rightwingsnarkle said...

Hiya, and greetings from a fellow head case. Just learned about yer blog from a freebie mag that arrived in the mail this week.

I mostly blog about politics, and see some fine fellow (gal) bloggers on your own roll.

I'll be back often.

Thx, RWSn

Anonymous said...

B teamers suck - of course no-one ever does anything about them. Afraid to because they cant hire replacements....

This is Sixty said...

I pray I get on the A team after graduation. Thanks for the primer on how to be an A-teamer. Is it possible to coaxe the B team over to the A team?

shrimplate said...

The team I work with is definitely A. It's just easier that way, the the job could do with less difficulties, no?

To "license pending," we'd be very glad to have you join us!

emily said...

Thanks for such an amazing post...leaves me wanting to point at your blog yelling, "Yeah! What Head Nurse said!!!"

....and I did. From both of my blogs. and

Thanks again.

Anonymous said...

My office (not nursing) went from A-team to B-team over the last year or so. I may have to change jobs to get away from the B-team and that's frustrating and annoying.

Elena said...

Great post. I sure hope I can land an A-team job after graduation...

Anonymous said...

Team work is always a requirement for the team to succeed.

Dr. Alice said...

Fantastic, you nailed it, and I completely agree. Here's best wishes for 2008 that you never get stuck on another B team.

lights n steel said...

I thank God everyday for the few A Teams I've run across in my short medical career. Thank you. I know that surgeons can be A and B quality, too. I hope you run into more A's than B's...

Rebecca said...

YES! You are so right on. I spent the last five years of my so-called career working with a *real* CCU A-team and the contrast was amazing. Not only did things get done correctly and in a timely fashion, but there were a lot fewer surprises involving patients who "unexpectedly" went bad. The staff all watched each other's backs, picked up the slack when they could and thought more about their patients than their social lives or their next cigarette break. That was one sweet unit and the attendings knew it too, at least the ones whose heads weren't permanently wedged up their butts.

The experience of working with a great A-team can have a lot with getting on day shift, which can take beaucoup years, especially if you change hospitals or units a lot. The new grads and hires will most always get stuck on night shift, which is often the refuge of the minimally competent and where preceptor programs are only a rumor.