Time to identify and correct structural defects - InSight+

“PANDEMIC” is the word for 2020 according to the Merriam–Webster dictionary. No wonder, as the global COVID-19 pandemic has transformed our entire society and exposed some of the darker aspects of human nature.

There is now well-established research showing that the pandemic has exaggerated and amplified pre-existing structural biases and systemic inequities in health systems.

Many of the structural drivers of health-related behaviors and outcomes such as racism have been broadly characterized, including the way the COVID-19 pandemic exacerbates these drivers. But far less attention has been paid to the role of organizational and systemic factors related to goodness.

The COVID-19 pandemic is revealing the unsettling truth about the issue of goodness in health. Health care workers experienced significantly more COVID-19-related bullying than people who did not work in health care settings after controlling for confounding effects, according to a study from 173 countries.

Another study from the US found that more than a third of registered nurses experienced greater incivility at work during the COVID-19 outbreak than before the pandemic (37.4%), and nearly half (45.7%) said they witnessed more rudeness than before the pandemic. before the pandemic. pandemic.

And in Australia, 35% of medical trainees in 2021 reported that they had experienced and/or witnessed bullying, harassment and/or discrimination (including racism) during their training. Recent reports of an increase in rudeness and bullying behavior provide evidence that the pandemic may have exposed a lack of good in health.

I wrote two articles about kindness earlier in Insight +the first one in 2015 was titled Return treatment, where I stated, somewhat naively: “we should always have time to show our patients that we care. We wouldn’t have spent a lot of money — maybe a quick smile, a caring touch, an extra minute to ask them how they were — instead of focusing solely on their illness or disease.”

The second, in 2016, was titled Kindness in medicine goes deeper than skin, in which I later stated: “As doctors and health practitioners, let us not only act good, let us also be good. As doctors, we can learn technical skills and knowledge and try to apply them to acts of kindness, but it is important that those actions are based on feelings of empathy and compassion, so as not to be perceived as artificial or forced.”

In both articles, I put the onus to be kind to individual physicians – something that most advocates of kindness in health do.

But is that the answer – telling unwell health workers, junior nurses and doctors, to learn to be better? Do we tell them to learn to be tougher and teach them coping techniques, and time management skills? There must be a place for individual training, and even organization-wide training programs on compassion and caring, and basic manners and manners.

But the problem is broader than just the individuals involved.

The COVID-19 pandemic has created a health workforce crisis, with unprecedented numbers of health care workers getting sick from infection, or isolated from exposure as a close contact. The threat of infection, the pressure of extra workload, and exposure to emotional trauma from the death of patients and co-workers, have led to a high prevalence of mental health disorders such as anxiety and depression in health care workers. This has in turn led to an exodus of doctors leaving the health system for less stressful, better paying jobs in other industries, which has created a vicious cycle leading to a strained health care system.

No wonder our health workers experience high levels of stress and fatigue due to physical and mental exhaustion. Instead of simply running a wellness program that pressures already stressed individuals to improve, true health requires organizational-level intervention and systemic change.

What do I mean by this?

In 1973, American psychologists conducted the now-famous “Good Samaritan” study at a religious seminary, which found that people who had less time and were in a hurry were less likely to be helpful and kind to others. This applies to seminary-study religious people who, as part of a psychology experiment, are ironically on their way to talk about the parable of the Good Samaritan (which is all about being kind to strangers), with some of them in the experiment. completely overstepping the victim on their way to the next building.

This study tells us that even nice people, who know deep down that they need to be nice to strangers, can skip expressing kindness if they feel they don’t have enough time to do so.

The first systemic problem we have in healthcare is that we don’t manage enough time for our doctors to be kind to each other and to their patients. Our schedule is designed to maximize efficiency and minimize costs. We enroll health care workers to reduce overtime and increase productivity. There is no time for good in our schedule.

In healthcare, we are always in a rush to go somewhere else, to do something else. This problem was exacerbated by the arrival of the pandemic, which removed many health workers from the roster, forcing the rest to work extra shifts and overtime. Our people feel so pressured and squeezed by the system that it’s no surprise that they feel they have nothing more to give.

Despite the high workload and pressure, healthcare workers continue to come to work, practice their skills and serve their patients. As healthcare system leaders and managers, we have a duty to ensure that our administration and support systems are designed in a way that facilitates the functioning of frontline physicians, and does not hinder or frustrate them.

We need to ensure that our stressed clinical workforce is paid on time, gets the IT support they need when they need it, and receives the right equipment at the right time to carry out their duties. Our healthcare workers need to feel valued and respected for the sacrifices they have made on our behalf, especially when so many have gone above and beyond the call of duty during these extraordinary times.

This means that we may have to pay some of our lowest paid health workers more adequately, such as those in our aged care system.

We cannot expect our doctors to be kind to our patients and to each other if the health system itself is not considered kind to them from the start.

The first step is to recognize that structural disadvantages exist in health, as do structural bias and racism. Our current healthcare system is designed to optimize cost and operational efficiencies above any other metric. While well-intentioned, this has led to the unintended consequence of having systems and processes that may be viewed as unkind and disrespectful by those working within the system.

We must continue to promote individual acts of kindness and teach our healthcare workers to be compassionate, but we cannot stop there. We must also address the problem of structural inadequacies in health, by conducting further research in this area, and redesigning health systems so that they look good to those who work in them, so that they can be kind to others as a result.

Professor Erwin Loh is Group Medical Officer and Group General Manager of Clinical Governance at St Vincent’s Health Australia.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policies of the AMA, MJA or InSight+ unless stated so.

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