“Status” is one of those topics that the more you study it, the more fascinating it is. Its connection to power, money, position in society, physical size or strength, educational level, majority culture and the ways it influences our relationships have great relevance to the ways we interact with each other and with our patients. Because of this, the idea of status could even have ramifications for healthcare issues such as patient safety and patient experience.
In Keith Johnstone’s seminal book for actors, Impro, there is a fascinating discussion about status and human behavior. Johnstone maintains that vying for high or low status positions in our relationships is going on constantly and that as audience members, we find status differences and changes interesting to watch.1 As such, mastering verbal and nonverbal expressions of status is an important strategy for theatre direction and performance.
The importance of status in military or police work can be appreciated where being in a high status role requires physical stance, facial expressions, a uniform, and perhaps a weapon that clearly state, “I’m in charge here!”
In healthcare we see examples of high and low status manifestations all the time. Some examples involve effective leadership and followership, collaboration among the healthcare team, and respect for self and others. For instance:
- A doctor uses an authoritative and directive tone in dictating the code team’s response to a patient’s cardiac arrest.
- A nurse uses assertive tone and body language while raising concerns with a physician about a patient’s clinical status.
- A nurse’s assistant sits down next to a patient with dementia while feeding him.
- A nurse practitioner speaks softly and is mindful of his body posture in order to lower his status and create psychological safety for an anxious patient.
Unfortunately, we can also all likely attest to seeing status used inappropriately or worse, in ways that interfere with safe care and optimal patient experience. For example:
- A nurse apologizes frequently, mutters, and covers her mouth when raising concerns about a patient’s clinical status.
- A doctor uses dismissive and humiliating language to belittle a nurse who raised concerns about a patient’s clinical status.
- A physician assistant assumes that her knowledge of the side effects of a medication is superior to a patient’s and discounts the patient’s report.
- A nurse’s assistant doesn’t knock before entering a patient’s room.
These nuances of behavior seem obviously helpful or unhelpful when illuminated like this, but as many leaders can attest, integrating the helpful behaviors and eliminating the toxic ones can be a challenging task.
Medical Improv as an Experiential Teaching Method
Understanding what high and low status behaviors look and feel like can help us use them in ways that will optimize our interprofessional and therapeutic relationships so that we can work together effectively. We discussed medical improv as an experiential teaching method to help with behavior change in a recent post about optimizing outcomes and approaching change differently. A variety of “status activities” can be used in improv training as a safe and effective way for healthcare professionals to gain awareness about their own tendencies and internalize how different ways of being might feel and how they impact others.
For instance, one activity is called the “Status Slide.” It involves playing a character with either high or low status and morphing into a character with the opposite status. For instance, I could start out as a patient with low status while a colleague plays the role of a doctor with high status. Over the course of a few minutes, I would gradually become a patient with high status and my partner would slink into a low-status doctor.
As the low-status patient I would:
- Speak softly and mutter
- Use a lot of words
- Feel uncomfortable with silence
- Apologize a lot
- Hunch my shoulders and take up less physical space
- Use a lot of anxious gestures like covering my mouth and fidgeting
- Squirm in my chair and sit on the edge
- Avoid eye contact
- Retract statements even when making sense
- Use facial expressions that indicate doubt, anxiety and/or low self-esteem
Meanwhile, my colleague acting as a high-status physician would:
- Speak clearly and audibly
- Use few words
- Seem comfortable with silence
- Never apologize
- Stand with legs apart and strong, open shoulders/arms taking up a lot of space
- Sit back in his chair relaxed, confident, and in charge
- Seek out eye contact
- Maintain confidence even when not making sense
As we switch our status levels, my colleague might become apologetic for his idiotic suggestions to treat my rash and I might leave in an arrogant huff because of his obvious incompetence. Can you imagine?
Granted, these kinds of activities require a little practice and a willingness to step out of one’s comfort zone. A safe environment is also very important. Facilitating a safe environment and progression of activities that are in sync with any particular group’s readiness for risk is crucial for this kind of work. Keep in mind that these behaviors are naturally human. Yet there are profound rewards in related discussions, awareness, and opportunities to internalize new behaviors and empathy.
Have you noticed how status affects interactions in your facility? Tell us how you are using medical improv and status exercises to improve communication, empathy and experience in your facilities. Share your stories and questions below in the comments.
- Johnstone, Keith. (1981) Impro: Improvisation and the Theatre. Reprint, Routledge Taylor & Francis Group: New York, 2015