What is human healthcare?
08 May 2018
Jocelyn Cornwell reviews some of the key questions arising at our conference on ‘making healthcare more human’, and the solutions identified.
Can you put your finger on human healthcare, what it looks and feels like for patients and for staff? Sometimes it’s easier to describe something abstract such as ‘humanity’ by its absence rather than to name the thing itself. At The Point of Care Foundation we believe the industrial scale of healthcare delivery and sheer size of modern professional bureaucracies puts human connections at risk, so we decided to devote a whole day to exploring what more human healthcare means and how to achieve it. Our ‘Making Healthcare More Human’ conference welcomed speakers and an audience that included patients and carers, and was designed intentionally to reflect the heterogeneity of the healthcare workforce.
One theme threading through the conversations on the day was that human means feeling fully oneself rather than feeling disempowered. Patients are disempowered if their feelings and words seem not to count, or to count less than other people’s and even more so when they feel they don’t count, as a person. For staff, feeling disempowered means feeling their organisation/employer sees them as a (replaceable) cog in a machine.
For patients, administrative processes and routines that tell rather than ask are disempowering. Examples include appointment systems that tell patients the time and date of their appointment (often nowadays accompanied by a threatening text that says if you do not attend you will be referred back to your GP and have to start the process all over again); automated telephone responses; and the all-too-familiar experience of answering the same question from different people who do not seem to be aware that you have given the same answers multiple times. We also heard examples of specific harms and insults to patients’ sense of themselves: a nurse treating an adult like a child, telling her to pipe down when she is crying out with pain; and an acute care of older people ward that routinely puts new patients into continence pads because it’s too difficult/time consuming to assess patients individually.
Although illness, by definition, disrupts the normal sense of the self that is able to cope and makes patients anxious and vulnerable, none of the patients who spoke at our conference, all of whom have experienced life-changing illness, want to be labelled ‘patient’. Tessa Richards, for example, talked about travelling hopefully, as “a person living with this rather strange condition” (a cancer so rare, that she had to research it herself). “I don’t like the patient label,” she said. “I still think I’m a person. It’s stressful wearing the patient hat and I try to take it off as quickly as possible”. For Jean Strauss, “What makes you a patient is how you feel and how you are treated.” Rhiannon Flood said seeking answers from doctors on how to cope with chronic fatigue was disempowering, and only found the help she needed when she stopped thinking of herself as a patient.
Cogs in the machine
For staff, the factors that make you feel like a cog in a machine are straightforward and prosaic. Non-clinical staff feel they do not count when people higher up in the hierarchy don’t ask their opinions about anything and leave them out of decisions that affect them. For clinical and non-clinical staff, the sheer volume of work means that missing breaks is becoming the new normal. People get used to overriding their physical needs for food and drink, and not even going to the toilet when they need to. There was talk of the lack of physical spaces to rest and relax during the day, away from patients‘ eyes and ears, which contributes to staff treating one another instrumentally, not feeling connected, and taking communication shortcuts more readily, such as addressing colleagues in object/non-human terms such as ‘the F1’, ‘the Band 3s’.
We heard that the junior doctors’ industrial dispute last year was about money and the lack of humanity in the machine. For example, trainee doctors rotate frequently spending relatively little time in any one area of clinical work and always having to find their feet with a new team. This pattern of work is created by design, but there seems to be no one in NHS trusts who takes responsibility for the trainees’ needs for relevant induction and ongoing mentoring. To add insult to injury, there have been reports of young doctors not being paid properly and receiving the wrong tax code because HR and finance departments do not keep careful track of their movements and lose sight of them.
Against this backdrop, of apparently small but always profound experiences, what can be done to make healthcare more human? In the course of the day, the solutions discussed fell mainly into two categories: actions open to individuals at any and all levels of organisations, and actions for organisations.
The actions for individuals start with looking after oneself. The idea that you must take breaks when they are due, must rest, and must take care to eat and drink regularly through the day, may be easier said than done, and may be counter-cultural. But as Suzy Wilson from Performing Medicine pointed out, just as airlines tell parents that to stay safe, they must put their own oxygen masks on before they help their children with theirs, staff have a responsibility for themselves that they can’t pass on to anyone else. “Even in a perfect healthcare system, there’s still a need for self-awareness and detail.”
For individuals, the conference experts in organisational development and human resources advised:
In terms of staff I would say the one thing they can do is, despite all the pressures, just stop before they enter work each day and remind themselves why they chose to go into healthcare and not leave their heart, souls and self outside the door. Because taking all that in the door with them will make the difference to the work they do that day and at the end of the day as a result ask themselves what they did that day that makes them feel proud.”
– Tracy Boylin
Open up to different kinds of communication that are going on – non-verbal, physical, spatial, symbolic, how we structure time. Become much more sensitive to it. One way is to learn about Unconscious Bias – understand how automatic judgements might be replicating unhealthy systems. Reflective conscious thinking and feeling is required to make good judgements. But much simpler is to create reflection time and space, Build it in, as we build in action time. When I think about some of the service improvement measurements that I carried out – we never measured time for reflection. Find ways of slowing down, not speeding up!”
– Amy Stabler
Other actions that rely on individuals behaving differently include taking care to flatten and soften hierarchies by introducing oneself clearly, using first names and reminding yourself to respect normal social niceties – sitting down to talk to a person in a bed rather than towering over them; making the effort to get to know people in the different tribes you work with as people, resisting the habit of using objectifying labels for patients and colleagues. Ben Morrin, for example, asked the audience to resist using the term ‘overseas’ to describe people who would otherwise be designated by their levels of skill or qualifications, and talking about ‘back office’ staff, thereby ignoring their contribution to patient care.
What can employers do?
The conference felt there is much employers can do, starting with getting the basics right, making sure HR and finance staff are incentivised to sort out basic problems of pay and terms and conditions as a corporate priority, and auditing the physical plant to make sure that staff can access food and drink, 24/7. Wherever possible, employers should be looking to create spaces where staff can rest and relax away from patients.
It’s also about employers communicating a positive vision of the workforce and their relationship with patients, celebrating diversity as an asset rather than a problem (as Ben Morrin’s trust does in this short film celebrating the 121 languages spoken at University College Hospital, London) and spending time with employees in different parts of the organisation, in different occupational groups, asking and answering questions. In other words, as leaders, modelling reflective practice. The Point of Care Foundation’s Schwartz Rounds offer a relatively simple way in which employers can demonstrate to staff that they value the care they provide for patients at the same time as creating a safe psychological space that is known to confer psychological benefits.
Beyond this, it is important for leaders to recognise the importance of one’s own words and behaviours as role models. Avoid using labels, always use first names, and make sure to wear a name badge are priorities that leaders can easily adopt which will make a difference.
Throughout our conference and in the discussions that have followed, we have identified many examples of how empathy between patients and staff, and between staff and managers, can enable human healthcare. Healthcare professionals showing empathy for patients improves care, just as managers showing empathy for staff improves working conditions and drives better quality care.
These approaches are neatly captured in the concept of reflexivity – or thinking about one’s self and one’s actions in relation to others. Research by Michael West shows that team reflexivity in healthcare is the key to successful team health and team learning. Ann Cunliffe talks about reflexivity as the foundation of relational integrity in organisations.
While it remains difficult to put a finger on exactly what human healthcare looks like for carers and patients, it is possible to see how empathy and remembering our shared humanity are the keys to ensuring it is maintained.