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December 9, 2021

It's not just 'burnout': Your workforce is facing moral exhaustion

Daily Briefing

    Amid the surge of the delta coronavirus variant, many clinicians have been forced to make difficult and potentially even unethical decisions when their resources are scarce.

    Radio Advisory's Rachel Woods sat down with Cynda Rushton, a Hastings Center Fellow and professor of clinical ethics at the Johns Hopkins Berman Institute of Bioethics and the School of Nursing, to talk about those decisions, what role leaders and administrators play in protecting frontline clinicians from those decisions, and what it means for those delivering care.

    Our take: Three strategies for health care workplaces to build baseline emotional support

    Read a lightly edited excerpt from the interview below and download the episode for the full conversation.

    Rachel Woods: How do you recommend leaders go about diagnosing and figuring out what's the spectrum of challenges that my workforce is feeling or that individual people are feeling? Is there a way to help leaders understand and diagnose in the moment what's happening with their workforce?

    Cynda Rushton: Yes, and I would start with the very simple practice of wholehearted listening, because what tends to happen under crisis is we go to transactional communication instead of empathic communication.

    What we hear over and over again is clinicians say nobody's listening, nobody cares. I think we have to start by really being willing to listen to the stories however painful they are and holding that without fixing it, but allowing the emotions to be able to be held and honored.

    So first we've got to create a space, a psychologically safe space where we can be vulnerable together. Right now, that's hard to do because I don't think people feel safe in themselves, they don't feel safe in their work, they don't feel safe in their teams and their organizations, they don't even feel safe in their communities or their homes.

    Everyone feels at the ready waiting for the next threat to show up. So we have to really create spaces where that can happen and where we can name and honor what is true, because until we name it, we can't begin to heal it or to release it.

    Woods: You mentioned earlier that these problems existed prior to the pandemic. Let me imagine a world where the delta surge at the very least, wanes. I'm not going to say that the pandemic ends, but at least we're out of this particularly difficult moment. Will these difficult ethical decisions go away, and will the moral suffering go away if that happens?

    Rushton: Well, I wish it was going to be that simple. I doubt it. First of all, these kinds of ethical questions are part of being a health care provider. It is the case that it goes along with our work. What is modifiable though, is how we respond to them. That I think is where the opportunity is.

    Denial that they exist is not a sustainable coping strategy. We have to actually turn toward these issues and say, "Okay, they are there. Let us engage in trying to understand the patterns in this organization that have contributed to them. How do we resource the people who are dealing with them on a day-to-day basis? What's missing from our own organizational architecture here that needs to be in place to recognize these issues more proactively, to be able to have systems where it's expected that people are going to bring these issues up, and we respond by saying, thank you rather than saying, 'Oh no, you're a problem because you're bringing up something we actually don't want to look at.'"

    I think we're going to have to get more comfortable being uncomfortable with these issues. There aren't easy answers, but we cannot turn away from them. We have got to turn toward them and we've got to figure out the balance between investing in things that help engage the inherent moral resilience of individuals in systems that have resources that are available to support them to do the right thing every time.

    Woods: Just like we can't expect individual clinicians to make these horribly difficult decisions. We need to create a system, whether it's a triage committee or otherwise, that protects them. We also need to create a system that protects them outside of just decision-making that supports the workforce more broadly.

    Rushton: Yes. I'll have to say, there's a lot of heartbreak in the midst of all of this. We've talked about mental health consequences of these kinds of situations. What we're seeing is clinicians are experiencing very significant mental health consequences; depression, anxiety, post-traumatic stress disorder, and even in extreme circumstances, suicide. What organizations have to really think about is it's not enough to tell your employees that you have a benefit for mental health services when those services are not accessible and are not perceived to be transparent and trustworthy.

    I have a colleague who is an incredible critical care nurse, who worked nights during the pandemic in a busy, intensive care unit. She showed up again and again and again. She realized that she had reached a point where she was not well in terms of her own psyche. She was experiencing symptoms of PTSD. She was feeling depressed. She asked for a leave of absence for 10 weeks. It took nine for her to get access to mental health services. That is a broken promise from an organization that communicates that they have resources.

    There's a failure around mental health access as well. And alongside that are all of the barriers that get in the way of clinicians using them; fear of retaliation, compromise in their job status, their license. To there are some bigger issues in terms of not only the moral domain, but how do we actually make good on our promise for the people who have given so much that we actually are going to support you and make it possible for you to be whole again too.

    Woods: I appreciate you sharing this story with me so much. What you're just beginning to scratch the surface on is the fact that there are even bigger risks that we're talking about here. There are bigger risks for the workforce. There are bigger risks for the trust-based compact between clinicians and their employers, frankly, between those hospitals and their patients and what it means to do high quality public health intervention in the United States.

    There is so much that we could keep talking about in terms of what to do next, but I want to end by just giving you a moment to speak directly to the folks who are listening to this episode. Whether they are a clinician themselves, whether they are a clinical leader or in any other part of the industry, is there one thing that you want them to take away from this conversation or one thing you want them to do differently at their home organization?

    Rushton: We have to name what's true and the incredible contributions and the sacrifices and the unintended consequences of this pandemic. I think if there's one thing we need to do is to restore the humanity in our health care.

    What I mean by that is we need to restore the humanity for the people we are serving, but we equally need to invest in the humanity of the people who are delivering care. That means to really make a commitment to live our values of respect of equity and compassion for everyone, and that includes the clinicians who are providing care on a day-to-day basis.

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