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Small, but mighty: “when you are doing all that you can, it is enough”

Cleo Williamson 06 January 2017

Cleo Williamson explores the power of seemingly small acts to make a big difference in healthcare


Small things, big difference

When I was little, my parents would always repeat clichéd phrases to me, one of which was: “Attitude is a small thing that makes a big difference.” Of course, as a child, I saw this as merely a classic parental phrase that I let go right over my head.

However, as time goes by, the truth of this old cliché reveals itself to me more and more: the attitude with which we approach something can have a huge impact on the outcomes; on how we respond to a situation and how it, too, responds to us. And yet this is not true of attitude alone: many ‘small things’, cumulatively, can make a ‘big difference’.

What really solidified this idea for me was a book that I read called The Path, in which Professor Michael Puett and Christine Gross-Loh discuss the legacy of philosopher Confucius, for whom ‘everything began with […] a question about the tiniest things.’

Confucius argues that when we always respond to situations with our emotional responses, we become trapped within patterned, habitual behaviours. Yet if we make small changes, and if these changes become ‘rituals’ (through conscious repetition), we change the habit:

A Confucian approach would be to note your patterns and then work actively to shift them. […] say, suppressing your usual sigh when your father starts in on one of his political tirades (even though you are irritated) […]. Over time, you internalize a more constructive way of acting in the world instead of being led by your undisciplined emotional reactions. Little by little you develop parts of yourself you never knew existed.

Actions taken ‘little by little’ can have a significant impact. In a mass-consumer society, it is easy to correlate ‘bigness’ with greatness: big bucks with big success, more followers with more friends, more possessions with a higher quality of life. But all of these ideas are open to question, and I like the idea of turning our attention to the small things. Of recognising the value of the little things that we do every day.

Schwartz Rounds case study

Increasingly interested in this idea, I was therefore incredibly moved when I attended my first ever Schwartz Round and found these very ideas emerging amongst staff as they reflected upon their practice. The topic of the Round was on patient safeguarding, and panellists discussed how sometimes they feel utterly powerless: they will intervene with the patient’s best interests at heart, they will recommend a course of action, but the patient will refuse to follow that advice. They end up feeling that they have achieved nothing.

Another concern is that they sometimes feel extremely limited: they will intervene as much as they can within the constraints of the law, but there comes a point where their power is limited. Does this mean that they have been unable to help to protect the patient? Have they failed?

This led to reflections amongst the audience about feeling inadequate, always feeling like all that they do for a patient can never be enough to ease the pain or provide relief. There was a repeated reflection about feeling inadequate; feeling so frantically busy; feeling spread too thinly, unable to help a patient in any grand way.

Yet, as one audience member pointed out, this does not mean that the small things that are done are not meaningful, and that they do not have a big impact on the patient’s treatment. She said that you have to remember that when you are doing all that you can, it is enough: you are using the resources that you have to make as many small impacts as you can, and this is in itself meaningful for the patient.

Indeed, it is on this principle that Schwartz Rounds rest: founder Ken Schwartz wrote an article arguing that the simple acts of kindness shown by healthcare staff had more of an impact on his experience than the medical treatments. When it comes to compassion in healthcare, the small acts of kindness are what makes the patient feel that they are a person before a patient; ultimately, the everyday gestures actually have a huge impact.

Small gestures are having an impact everywhere

As NHS staff come under ever-increasing pressure to meet financial and performance targets – the ‘big’ measures – I think it is important that these smaller gestures are remembered. If staff are doing these things, they are still having a meaningful impact.

It seems to me that stories of staff doing ‘small things’ which make a ‘big difference’ to a patient’s experience are, in fact, everywhere, if we look hard enough:

Take, for example, the intensive care unit staff in the US whose kind actions eased the pain of a patient and her husband. They apologised as they administered her injections; pulled her gown up whenever it slipped; placed a blanket over her when the room got colder.

Or the porter who simply by relating to one particular patient on a personal level created a bond which was meaningful and lasting. Rob revealed his humanity when he was lost for words, so instead he simply rested his hand on a dying patient’s shoulder. A small gesture, but a great emotional cost – and of great significance for the patient, I am sure.

The more that I hear such stories, the more I am reassured that these little things really do make a big difference. Do not get me wrong, the big things are important: clinical knowledge and its application are, of course, vital. But when the ‘big’, clinical tasks feel somewhat inadequate or like they fall short, or when staff worry that they have made no meaningful impact, I think that they should not forget nor doubt the importance of all the small things that they did.

Though I hate to admit it, my parents were right after all: a small thing can indeed make all the difference.