We are not helpless victims of the system, write Hearts in Healthcare co-founder, Robin Youngson.
“We just don’t have time to care!” is the heartfelt protest of health workers in every country we visit. This is the reality of modern healthcare – always being asked to do more with less, in a frantic and stress-filled workplace. Health professionals going home exhausted, not with the satisfaction of a job well done but fretting about care too hurried, and patients neglected.
Yet, amidst the storm, some remarkable health professionals create a circle of calm. They go about their work in an unhurried way, finding time to greet their patients, put them at ease, listening deeply and offering kindness and compassion. They don’t neglect their clinical tasks, indeed they seem to get the work done with quiet efficiency. These inspiring workers go home with satisfaction and joy in their hearts. How is that possible?
The truth is, our health system rarely encourages or rewards compassionate care, or spending enough time with our patients. On the contrary, we work in a system that systematically bullies, brutalises and burns-out health professionals. What secrets do these inspiring workers know? How do they flourish in a system beating down everyone else? As we travel the world we hear more doubt and cynicism than hope: ‘Maybe it’s possible in some other workplaces,’ people think, ‘but not where I work.’
Dr Anju Yogakumar would disagree with you. She works as a primary care physician in an urban setting riven with poverty and disadvantage. In her clinic, there are no appointments, patients simply wait hours to see a doctor for a small fee. On a bad day she’s seeing fifty to seventy patients – and these are typically patients burdened with a terrible weight of chronic health conditions, not the worried well. Even in this challenging work setting, Anju learned the art of compassionate caring. It totally transformed her experience of the workplace – ‘All my stress is gone!’ she said. Her new practice also changed the lives of her patients. Read her story here.
The art and science of making time to care.
If you observe the practice of compassionate health workers you do indeed find magic. Time appears to slow down. Difficult patients and lists of problems seem to dissolve away. Interruptions are infrequent. The job gets done with an ease and a skill that’s hard to define. Patients smile and laugh and sometime cry. There are moments of deep stillness and quiet. Less is done but more is achieved.
Behind the magic lies rigorous science. Compassionate practitioners are intently mindful and deliberate in their approach to each patient. Many of the practices are counter-intuitive yet they are backed up with sound research and practical wisdom: If you don’t have time, slow down; If the patient makes too many demands, invite more!
At Hearts in Healthcare we have painstakingly gathered the evidence and learned from the masters. Here are the seven strategies we know make a practical difference. Each strategy is a matter of personal choice – you don’t need permission from your boss or help from your teammates. The same strategies can be applied by the student nurse or the senior doctor, they are universal.
A note about references: I’m not going to quote the references in this article because I have a better offer. I’m giving away my entire slide collection (120 slides!) and every PowerPoint slide has extensive notes and all the scientific references.
We want you to study the evidence and then use the slides to build your own presentation and share the message. For a brief summary of the evidence, see our free info-graphic, ‘Top ten scientific reasons why compassion is great medicine.’
1. Remember that compassion and caring have no dimensions of time
Saying ‘We don’t have time to care,’ is actually rather an odd thing to say. Caring has no dimensions of time, it’s an attitude, not an action. Here’s a story to illustrate the point. A friend of mine, in his seventies, has suffered all his life with a chronic chest condition, which lands him in hospital every few months. He has a lot of practice being in the role of a patient and – as an organisational psychologist – he’s a great people watcher.
He describes the scene when at 6am his sleep is interrupted by the nurse coming to administer his dose of iv antibiotics. She bangs open the door, switches on the bright room light, marches up to his bed and roughly pulls back the bedclothes to check his id band. After flushing the iv line, she injects the dose of antibiotic, records the dose, then marches out the room leaving the light on. ‘There is no possibility of sleep,’ my friend says.
The next day, another nurse attends at 6am to do the same task. She tiptoes quietly into the room and uses a torch so that she doesn’t have to turn on the room light. She gently checks the id band and quietly administers the drugs before tiptoeing out of the room again, leaving him to sleep. ‘Which nurse was compassionate?, my friend asks.
The point of the story is that when we are busy doing our necessary clinical tasks, we can do so with an attitude of loving kindness, or else with brusque efficiency. We can greet our patients with a smile and engage them in conversations about their needs, or else make them know how harried and busy we are. Each takes the same amount of time. Caring is an attitude, its a quality of being.
2. Invest time to save time
The research evidence is really clear that our own actions create much of the patient demand that overwhelms us. When we treat symptoms and complaints, rather than root causes, our patients will always return for more. When we impose our own clinical agenda, instead of truly listening to each patient’s needs, we create enormous amounts of unnecessary work and expense. When patients feel neglected and unsupported, they suffer far more pain and complications. Our frantic pace of work is generating enormous amount of rework and leaving our patients dissatisfied.
On the other hand, compassionate care remarkably improves patient outcomes, dramatically reduces rates of interventions and costs, and helps our patients be more resilient. The key is to invest some time up front at the beginning of each patient encounter.
Here’s some of the surprising research data:
A study in Canada showed that when primary care consultations are truly patient-centred and the doctor and patient find agreement, the number of subsequent tests was reduced six-fold, and the number of specialist referrals was more than halved, compared with care that wasn’t patient-centred. Those patient who had fewer test and referrals made a better recovery from their illness.
A similar study in the USA observed more than 500 patients for a year in family and general internal medicine. The fifty percent of patients who received less than the median amount of patient-centred care in consultations had annual healthcare costs – including hospital care – 50% higher than patients above the median. The ability of the doctor to listen to the patient is the most significant driver of healthcare interventions and costs we have ever found!
A randomised controlled trial in an ER gave all patients ‘usual medical care’ but half had an additional ‘compassionate care intervention’. What was that? – Simply a volunteer sitting down and talking with the patient. This intervention led to a 30% reduction in repeat visits to the ER for the same condition, in a series of patients who were ‘frequent attenders’. This result begs the question, ‘What is missing from usual medical care?’
As an anesthesiologist, I reduce my workload for every patient by investing some compassion and caring up front. How does that work? Randomised controlled trials show that when the pre-operative consultation is empathetic, supportive and compassionate – as opposed to just giving standard information – the patient needs only half the dose of morphine after surgery, the surgical wound heals more quickly, patients have less pain and less anxiety, the surgical outcomes are better, patient mobilise more quickly, and are discharged from hospital earlier. Boy, does that save a lot of work!
What I notice in daily practice is that my patients recover so well from anesthesia. I’m rarely interrupted to attend patients in the post-operative recovery unit because they’re rarely in pain, they’re not vomiting or having other complications. Moreover, the OR list goes exceptionally well. Compassion and caring is not just for the patient, it’s for your colleagues. Teamwork is better, communication and planning is improved, people are less stressed, there are more smiles in the OR, the surgery goes better. At the end of the day, the surgeon’s in a better mood, not stressed and frustrated.
3. Find out the patient’s concerns before you begin your clinical agenda
In a famous study, much quoted, 77% of doctors interrupted their patients’ opening statement of concern at the beginning of the consultation. How quickly did the doctors interrupt their patients? On average, within 18 seconds!
For most of my career, I was intently focused on the clinical agenda for each patient. To fully assess and prepare a patient for anaesthesia, I have a lot to do and not much time. After a brief introduction I’d dive into an efficient routine of assessing the patient’s medical status, doing the routine anaesthesia checks, and completing informed consent. When I asked patients if they had any question, they usually demurred. I was always polite and friendly but completely unconscious of how powerfully I controlled the agenda of the consultation.
Now I begin my consultations in a very different way. I take a lot of trouble with introductions. I don’t just give my name and tell patients I’m the anesthesiologist – I tell them that I’m the doc with the sleeping medicine. I say my job is to put the patient to sleep, to be in the OR every single minute of the case watching over them making sure they are asleep and safe, and that they wake up comfortably when the surgery is finished. This is a very deliberate script: I’m positively stating my intention to care, I’m employing suggestion to enhance a good recovery, and I’m saying that I’m going to be there for them.
The reality is, most patients are really confused about all the different health professionals they meet. On the day in the OR, I might be the sixth person in identical blue scrubs to appear before the patient. Am a nurse, a surgeon, a trainee doctor, a student, an orderly or a technician? We all look the same to patients.
Before I begin any of my clinical agenda, I greet the person as a human being – rather than just a patient – and put them at ease. I always get down to the level of the patient and avoid standing over them. Often I ask permission to sit on the patient’s bed, find a chair, or else kneel on the floor beside them. Having made the human connection, I become very still and attentive and ask how the patient is feeling. I watch carefully for signs of anxiety. Often I ask, ‘Did you get any sleep last night? What were the thoughts going through your mind as you lay awake at 3am?’
In every single patient I find out their fears and concerns. Sometimes the patient asks me questions about the surgery and it becomes clear the patient has little understanding of what the surgeon said – so I go and find the surgeon and bring them back to the bedside.
When the patient expresses a fear, I don’t first offer reassurance because that just dismisses the fear. Instead, I empathise with the patient and I validate the fear – for instance if my patient expresses a fear of waking up half-way through the surgery and being paralysed and unable to move – I say that’s a real thing, a very traumatic experience.
Then I put it in context. I say that in thirty years of practice I have met a handful of patients who had that trauma but not one of my own patients has ever told me they were awake, when they were supposed to be asleep. In some forms of anaesthesia, such as a spinal anaesthetic, patients choose to be awake.
I describe the sophisticated monitoring we have during the anaesthesia – like the flight deck of an aircraft – and I have already emphasised how I am going to be watching over the patient every minute of the case. Then the fear is gone, I see the patients relax. We have a bond of trust.
This skill in eliciting patients’ concerns developed late in my career. For many years, patients never confessed their deepest fears, or I didn’t find out until the end of a consultation – and then I’d have to start all over again.
It might sound like this is going to take a long time with each patient. If we start exploring all the patient’s fears, aren’t we just opening a Pandora’s Box of endless concerns? My experience says, ‘No.’
The reality is this: I’m anaesthetising a list of eight patients during the day. Because of scheduling, I am only able to see a couple of the patients before the surgical list begins. Between every other case, I have to leave the OR, go to the pre-op admissions area, find my patient and the charts, and do the whole pre-op consultation and consent. The surgeon and the whole OR team may be waiting impatiently in the OR for my return. Despite the time pressure, I invest this time up front with every single patient I anaesthetise. You know what? We always finish our list on time!
What I learn about each patient is so valuable for patient care that my whole day just goes much better. I make better plans, I have fewer surprises, the patients are more stable in the OR and have fewer problems and complications in the post-anaesthesia care unit. It’s easier to insert the iv line in each patient because they are relaxed. Nervous patients constrict their veins and you can waste twenty minutes on one patient trying to insert an iv line – plus you are hurting the patient with multiple attempts.
I’ve given an example from my own medical practice but the exact same principles apply to nursing care. Most nurses work in a fraught environment and they are rushed off their feet. It’s hard to get work done because of frequent interruptions. The call-buzzers are going flat out. The reality is frightening: a survey of hospital nurses working in a busy NHS hospital in the UK found that 90% of the nurses had not been able to complete important clinical care tasks during their shift because of busyness and overwork. But nurses who learn to make the human connection with their patient have a very different experience.
The key is to find out your patients’ concerns and needs up front. One inspiring nurse we met was nicknamed ‘The Angel’ by her workmates – she had such a caring manner with patients, who all loved her. How did she start her morning shift? She collected a clean wash-cloth for each of her patients and moistened them in the sink; then warmed them in the microwave oven. Handing each of her patients a warm wash-cloth – just like the air stewards do on Singapore Airlines! – she’d ask them how she could best attend to their needs and comforts that day. What she learned in that few minutes with each patient, she said, transformed the care she gave during the rest of the day.
Many hospital have implemented ‘Hourly Rounds’ for nursing care. No matter how busy the nurses are, they stop their tasks each hour to round on each of their patients and pro-actively find out their needs: do they need to go to the toilet, need pain-relief, have all of their belongings within reach, have any other needs for comfort? The research shows that hourly rounding dramatically improves the efficiency of nursing care. Call-buzzers fall silent. Nurses can get their work done without unplanned interruptions. Patients feel much more satisfied and cared for.
Typically, the research shows that hourly rounding can free up about an hour of nurses’ time during a shift – time to provide the face-to-face personalised care that nurse so dearly want to deliver to their patients. One study asked nurses to wear pedometers. Those who adopted hourly rounds walk a mile less each shift than those who didn’t.
Hourly rounding also has a major impact on patient safety: in the hospitals that adopted this practice they witnessed a large reduction in patient falls, and also the incidence of bed sores.
The old saying goes, ‘A stitch in time saves nine.’ This is never truer than in our frantic health workplaces. Busyness and overwork create chaos; chaos creates yet more work and stress. The antidote is to slow down. It’s counter-intuitive but it works like magic!
4. Learn how to serve your patients, rather than always fixing and helping
Rachel Naomi Remen, a pioneering US doctor promoting compassionate care, wrote a great paper about ‘Fixing, helping and serving’. I trained for fourteen years to become an anesthesiologist and I thought it was my job to be the expert, fixing and helping my patients. I had no idea of ‘service’ – what does that mean?
Remen pointed out that in both ‘fixing’ and ‘helping’ we are making judgments about our patients, and also retaining all the control. If we try to fix patients, we are saying in effect, they are broken. Sometime that’s appropriate – if I had a broken leg, I’d like the doctor to fix it. But if I suffer from a chronic disease, I can’t be fixed. I want support to live my life well, not just be offered another drug prescription.
Similarly, when we help patients – which seems laudable – we are making a judgement that the patient is helpless. Every time we rescue and help a patient, we are reducing their capacity to help themselves. With all of our fixing and helping we’ve created a culture where doctors are now apparently responsible for every illness and every unhappiness of all the patients. Patients in turn come to the medical clinic expecting an instant fix – give me a pill, doc! No matter that the illness is the end result of years of self-neglect.
When, instead, we serve our patients we radically shift the power relationship. It’s the patient who sets the agenda. As a highly trained health professional, instead of imposing my clinical agenda, I bring my knowledge, skills and power in the service of the patient’s life. It’s a liberating way to practice.
To serve our patients we need to become more humble. We need to appreciate the extraordinary healing power contained within every human being and that when patients recover from illness, our medical treatments often play only a minor supportive role. The outcomes for our patients are determined by many factors far beyond our control. All doctors who have practiced long enough learn this humility. Cancer patients completely defy our expectations and survive decades with what was supposed to be terminal illness! Others turn their face to the wall and decline rapidly. Sometime the most profound thing we can do is simply sit with our patients in their darkest places, and not turn away. Out of those crises, healing emerges within the magic of a compassionate connection.
It helps to let go of our attachment to patient outcomes while still bringing all of our careful caring, knowledge and skill in service to our patients. Open-hearted compassion without attachment is very different from clinical detachment, which can be cold-hearted.
To serve our patients we need to learn how to listen deeply. We need to let go of judgement. We need to see each patient as a marvellous human being, full of capacity for health, healing, wellbeing and resilience. Rather than just focusing on the problems of our patient, we can begin to explore their strengths.
Patients often come with a long list of complaints. When we make the human connection, create a bond of trust, and listen deeply we can often uncover the hidden foundation of an illness. When we attend to that, all the complaints dissolve away. Patients stand taller, they find more confidence and a greater capacity for self-care. I’m astonished how different my consultations have become. We get to the heart of the matter so quickly.
I mentioned the inspiring Dr Anju Yogakumar at the beginning of this article. How did she transform her practice? Her strategy was simple. Each day, no matter how busy, she would choose just one of her patients and give them all the time they needed – even if it was an hour. She would listen intently, get to know her patient, build trust and partnership. She decided not to worry about the patients in the waiting room, just the one she had with her. In the course of four months, she transformed the relationship she had with all of her regular patients. Now she can often deal with a problem quickly, in just a few minutes. Her patients’ outcomes improved dramatically and they all love their ‘new’ doctor. Anju said, ‘The feeling I had that I had to fix all my patients, I don’t have that feeling any more. All my stress is gone.’
For me, one of the biggest reliefs was not having to be the expert all the time. Because I developed the capacity to really listen to my patients, I often uncovered problems that fell outside my area of expertise. I’d simply tell my patients, ‘I don’t know the answer to that question but let’s see if we can get you some help!’ Using my network of connections and knowledge of the system, I could pick up the phone, make a referral, or look up results on the computer. Supporting patients in this way gives me a great deal of pleasure. It also prevents a great deal of re-work and patients simply bouncing from one doctor to another without ever having the problem addressed. I do all these things in my routine, busy clinics but I still finish on time each day.
No matter what kind of health professional – or student – you are, choose to do small acts of kindness for your patients. One of my former nursing colleagues – I’ll call her Mary – saved her career by adopting this daily habit. At the time she was feeling dispirited and worn out and considered quitting her job. This is the story she told me.
Mary was referred a frail old patient with multiple medical conditions and partial blindness. When she began her assessment, she noticed the patient was distressed. She paused and asked if there was something she could do to help. This little old lady hesitatingly told her that she was extremely worried about some circumstance at home and she urgently needed to use the phone.
‘Did you ask the staff? queried Mary.
‘Yes,’ said the old lady. ‘I have asked every day to use the cordless phone but they keep telling me that’s only for staff and I should use the patients’ card phone down the corridor.’ Her lips quivered and she shrugged her shoulders. ‘I can’t use that phone, you see. I’m almost blind.’
In that instant, Mary decided to act. Excusing herself, Mary hurried to the hospital shop and purchased a phone card. Returning to the ward, she asked her patient, ‘Who is it that you need to call? I’ll give you a hand.’
Taking her by the hand, Mary led her to the phone and helped her make the connection. The little old lady cried. This was the first time in two weeks that anyone in the hospital had listened to her concerns. On that day, the patient began her recovery: the chest pain and heart failure began to abate.
Mary reflected on this event during the day and talked about it at home. She came to realise that this simple act of kindness was the single most satisfying thing she had done at work for a long time. Lately she had been feeling tired and dispirited. By the next morning, Mary had re-conceptualised her professional role: kindness first, expertise second. She looked for an opportunity each day to perform an unexpected act of kindness.
As she told me this story, her eyes lit up and her face became animated. ‘It’s like I have a new job!‘ she said.
5. Don’t worry if you are junior or inexperienced – you have a fully formed heart
In a day-long workshop with sixty junior doctors we explored what compassionate care means and how powerfully it can impact on patient outcomes. In the closing round we learned something new. Many of these first, second and third year doctors struggled with feeling inexperienced and incompetent – partly a result of the brutalising nature of medical training, which too often teaches by humiliation. But at the end of this day, these doctors showed a renewed sense of competence and purpose.
The truth is, every young health professional comes with a fully formed heart and a capacity for compassion and caring. Even if new graduates feel uncertain of their technical knowledge and skills, they are fully competent as caring human beings. Learning that compassionate caring can influence patient outcomes as much as the medical treatment, gave these new young doctors a new way to feel good about their contribution – especially important as surveys show 50% of young doctors have symptoms of burnout.
We feel sure the same is true of all new health professionals, whether they are nurses, technicians, therapists or midwives. Indeed, in our travels we have noticed that it’s the new graduates that often have the most open hearts. They have not yet succumbed to the exhaustion and cynicism of their elders. Investing in the strategies we outline is the best way to protect yourself from burnout.
6. Compassion is for your teammates and your boss too
Kindness is contagious. A recent controlled study in a large company seeded the workplace with acts of kindness performed by nineteen workers, who were enrolled as collaborators by the researchers. They were free to imagine and offer their own acts of kindness but offered them to only half the workers. At the end of a month, the workers in the intervention group were noticing ten times more pro-social behaviour than in the control group. Furthermore, those who received acts of kindness paid it forward to others; by the end of the study, the receivers reported engaging in nearly three times more prosocial behaviours than did controls.
Healthcare workplaces are stressed and bullying is commonplace but if just a few workers bring an intention of compassion, caring and kindness to their colleagues, the whole workplace culture can change for the better. Giving has health benefits too – in this study the givers enjoyed higher levels of life and job satisfaction, and fewer depressive symptoms.
Reach out to your colleagues when they are stressed or distressed. Many health workers take on a superhero role and hide their emotions. A willingness to show some of your own vulnerability can open up others to seek support when they need it.
Don’t forget your boss. There’s almost no research on the rates of burnout among health managers but in our experience of working with health executives we’re witnessing intolerable levels of stress and distress. In one groups of 24 health executives we asked each participant to anonymously score themselves on the question, ‘In the last 30 day, how many days did you feel unwell because of emotional problems or stress?’
The results were horrifying. One executive said 30 days out of 30, one said 26 days, one said 20 days, two said 15 days, three said 10 days. This was not feeling a bit stressed, this was actually feeling unwell because of stress or emotional problems. Based on those scores, if I was an occupational health physician I would have put one third of the executives on immediate sick leave.
If you want your bosses to pay attention to workplace wellbeing, you might start by asking how they are doing? Health executives often find themselves extremely isolated and the traditions of executive leadership don’t encourage vulnerability or reaching out for help. Reaching out to your boss could be the start of a remarkable change in the workplace.
7. Compassion begins with self-compassion
Many health professionals are highly self-critical. Harshness and judgment towards ourselves is sometimes reflected in our judgment of others. If we can learn to be kind and forgiving towards ourselves, we soften our exterior too.
One of the necessary components of compassion is the ability to tolerate distress within ourselves. When we witness the suffering of patients, we feel pain too. Compassion asks us to stay in that uncomfortable place and not turn away. So our first duty is self-care. We must not neglect our own health in the rush to help others. We need to make good choices about reasonable work-life balance, to ensure we eat a healthy diet, get regular exercise, and spend time with friends outside of the workplace. For free resources on self-compassion, you can visit the website of the authority on this subject, Kristin Neff. She says, ‘With self-compassion, we give ourselves the same kindness and care we’d give to a good friend.’
If all else fails, maybe you need to quit your job?
Some workplaces are just so toxic that it’s nearly impossible to be the kind of health professional you want to be – and your own health is seriously threatened. I’m often asked for advice by stressed health workers who feel trapped in their workplace. As more people leave, staff shortages reach critical levels. Health professionals are so incredibly dedicated to patient care that they often tolerate this kind of situation for months or even years – to the point of burnout. They present me with an agonising dilemma: ‘If I quit my job I will leave my colleagues in the lurch and my patients will suffer – but I don’t think I can keep going much longer. What can I do?’
I’ve reflected long and hard on this question and this is the answer I give: I want you to think about the sum total contribution to patient care you will make in the rest of your career. If you find a more supportive workplace, that allows you to work at your best, your lifetime impact on patient outcomes can be much greater. Furthermore, the only way that healthcare substantially changes is for bad workplaces to crumble and die, and good workplaces to grow and expand. Choosing to quit your job, although it involves short-term pain, is ultimately an ethical decision.
For an inspiring example of how this kind of change can work, see the story of Buurtzorg, the community nursing care provider in the Netherlands. Starting with just four nurses in 2007, it grew quickly to eclipse almost the entire national service as nurses quit the old system and joined the new. Buurtzorg not only transformed outcomes for patients, it offered nurses the opportunity to work in completely autonomous, self-directed teams providing whole-person, compassionate care. Buurtzorg nurses have voted their workplace the ‘Best Employer’ in the Netherlands for four of the last five years.
Joy at work
It’s a habit of health professionals to always focus on problems, not strengths and solutions. In that vein, so much of the research about the wellbeing of health professionals focuses on burnout. At Hearts in Healthcare we met some health workers who were joyous and resilient and we became curious. How did these remarkable health professionals flourish in a system that was beating down everyone else?
Using a questionnaire to measure joy and meaning in work, we identified respondents with an unusually high score and interviewed them. What were their daily habits and practices? One striking feature was that they chose to love their work. They didn’t dwell on all the frustrations of the workplace but spend time feeling deep gratitude for the privilege of the work they do, the daily opportunities for human connection, knowing that they made an extraordinary difference to the lives of their patients.
Other than that attitude, they all shared a set of daily practices: compassionate care. They employed all of the strategies we shared in this article.