Leadership for Compassionate
Healthcare:
Rhetoric or reality check?
Dr Kay Mohanna FRCGP
Prof of Values Based Healthcare Education
Organisational culture
Or personal responsibility?
Why?
•
Lack of time: eg GP -15 per cent overall increase in contacts: a 13 per
cent increase in face-to-face contacts and a 63 per cent increase in
telephone contacts; [1]
•
Shortage of workforce and squeeze on co-professionals
•
Cuts - to social care, public health plus the Nicholson Challenge
•
“Deflection, Delay, Denial, Selection, Deterrence, Dilution”[2]
•
Having to comply with ill-thought through imperatives that get in the
way of the real work. Eg admission avoidance care plans
1.The Kings Fund. Understanding pressures in general practice. May 2016
2. Robertson R Six ways in which NHS financial pressures can affect patient care Kings Fund March 2016
Compassion fatigue
A specific type of clinician burnout
• Impacts between 20% and 70% of doctors and
other healthcare professionals (Fernandez
2014).
• Nearly half of patients and doctors in a US
study felt that compassionate care is missing
in the health care system (Lowne 2011).
Empathy and compassion
• Empathy: the cognitive ability to recognise
another’s distress
• Compassion: the driver to intervene from
experiencing that distress alongside the
patient
Unhelpful?
Holding such emotions at arm’s length, is often
felt by professionals to be protective against
burnout (Smajdor 2013)
Black Humour
A release valve against the corrosive effect of reliving distressing emotional experiences in too
much depth?
What does it take to be
compassionate in practice?
The next patient, Diana Jones, is well known to you. Many years ago, when you first met, she was a
flight attendant. She is now, aged 37, with a significant alcohol dependency. You know that she has
recently got married to man she met in rehab. Today she has been brought to see you by her very
caring mother, also your patient, who regularly cajoles and pleads with her to attend outpatients,
stop drinking, take her medication and generally look after herself better.
“I wonder if you can prescribe a tonic for Diana, doctor, to build her up and get her fit” she says. “I
would like to see grandchildren before I die.”
Diana tells you that she and her new husband have been trying to conceive for about 2 years, have
both cut their drinking down, but that she recently fell and broke her wrist and was told her bones
were thin. You know her husband, he has three children with two other women and there is an
injunction in place against him seeing any of them due to domestic violence
Mid way through morning surgery Sarah walks in. She is deeply jaundiced and you can see she is
fatigued. Sarah retired early on ill health grounds from her position as a ward sister on ITU. She is
married to an HGV driver originally from Turkey, who has non insulin dependent diabetes and they
have a daughter training to be a solicitor and a son at University. She was diagnosed when she
collapsed in pain, at work, and was admitted and found to have metastatic ca caecum.
“I’ve come to ask you to keep an eye on Mahmoud when I am gone,” she says. “All his family are in
Turkey, so he won’t have much support and I am worried he won’t look after himself. Can you make
sure he comes for his check ups?”
By this time surgery is over-running significantly. Alongside the next name is a note from reception
that this patient’s husband had been extremely aggressive when booking the appointment. When
you call her through, Sean and Karen Hart walk in together.
“We won’t take much of your time doc,” says Sean. “So we thought you could squeeze us both in.
It’s harder than trying to get an audience with the Pope to see any of you lot. I just need my usual
sick note and antidepressant and the wife needs her morphine, gabapentin and mirtazapine.”
“I have run out of my morphine early,” adds Karen, “because Sean did his back in and was using
mine, so the receptionist would not issue my repeat.”
You see that the most recent entry on Karen’s notes is a court report from an orthopaedic surgeon
on her complex regional pain syndrome dating from slipping and falling in a supermarket
Have a think for a moment…
Reflect on how you are feeling..
Perhaps tell your neighbour
• Diana and her mother
• Sarah and her family
• Sean and Karen
Mindfulness
Proponents of mindfulness suggest that it allows
clinicians to become more aware of their own
psychological processes, biases, and prejudices,
to enable them to become more flexible and
hence perhaps better attend to the patient
“compassionate leadership is
everyone’s business”
• it is a wicked problem that demands a clumsy
solution... It demands a new way of leading
• I disagree…
• The role of the manager/leader is pivotal.
They connect individuals and teams to their
own humanity and core purpose
• I disagree…
• Only individuals can do that
• But they need courage and resilience
How can VBP help?
A framework for thinking with
Values
Values are anything positively or negatively weighted as a guide to action (for example, needs,
wishes and preferences).
Values-based practice is a process that supports health care decision making where complex and
conflicting values are in play.
 Complex values are values that mean different things to different people (for example, ‘best
interests’)
 Conflicting values are values that are in conflict one with another (for example, there are
often tensions in health care decision making between ‘best interests’ and ‘freedom of
patient choice’)
Medicine’s values tool-box
Values-based practice is complementary to other tools in medicine’s values tool box
 The values tool box is the range of disciplines concerned in one way or another with values
in healthcare (examples include codes of practice, medical ethics, medical law, decision
analysis, health economics, narrative-based medicine and others (including the
psychological and social sciences, medical humanities, history, literature, philosophy, visual
arts, etc))
Values-based practice complements other tools for working with values in focusing particularly on
the unique values of the particular individuals concerned (as clinicians, patients and carers) in a
given clinical situation
The premise of values based practice:
Mutual respect for differences of values avoids moral relativism (‘anything goes’) by marking out
excluded values and by shifting the emphasis in decision-making from pre-set ‘right outcomes’ to
good process
 Excluded values are values (like racism) that are incompatible with the premise of mutual
respect and hence (however widely shared) are by definition excluded from values-based
decision making
 Good process in values-based practice is decision making that is guided by one or more of
ten key process elements of values-based practice (see below)
The 10-part process of VBP
• 4 key clinical skills
• 2 aspects of professional relationships,
• 3 close links with evidence-based practice,
• 1 dissensual basis for partnership in decision
making
Clinical skills
1. Awareness of values includes awareness of the diversity of individual values, awareness of
clinicians’ own values as well as the values of others, and awareness of positive values (StAR
values, ie strengths, aspirations and resources) as well as negative values (such as needs and
difficulties)
2. Reasoning about values in values-based practice is aimed at expanding our values
horizons rather than (directly) to decide what is right
3. Knowledge of values as derived from research and clinical experience has the
important limitation that it can never ‘trump’ the actual values of a particular individual.
4. Communication skills include skills for eliciting
Professional relationships
1. Person-values-centred practice: focuses on the values of the patient, being aware of and
reflecting the values of other people involved (clinicians, managers, family, carers, etc): this
is important in tackling two particular problems of person-centred care, problems of mutual
understanding and problems of conflicting values
2. Extended multidisciplinary team work is practice that draws effectively not only on the
diversity of skills represented by different team members but also on the diversity of team
values: this is important both in identifying the values in play in a given situation and in
coming to balanced decisions about what to do
Partnership in decision making
 Consensus involves differences of values being resolved (as in the development of shared
frameworks of values)
 Dissensus involves differences of values remaining in play to be balanced sometimes one
way and sometimes in other ways according to the particular circumstances presented by
different situations
“Cultures of engagement, positivity, caring,
compassion and respect for all – staff,
patients and the public – provide the ideal
environment within which to care for the
health of the nation. When we care for staff,
they can fulfil their calling of providing
outstanding professional care for patients.”
West et al. (2011)
Cultures of engagement:
SELECT WELL FOR PERSONAL ATTRIBUTES
• Internal locus of control
• Pro-social behaviour
• Optimism
• Ability to organise
• Courage to speak out
BUILD WELL FOR HEALTHY ENVIRONMENTS
• The built environment
• Pastoral as well as health care
• Visible, responsive leadership
TAKING RESPONSIBILTY
• Noticing
• Speaking out
• Problem solving
Resilience of Healthcare Professionals
Identify your own risk and protective factors
Share experiences of both vulnerability and resilience so
that others may learn from—and perhaps emulate—the
strengths and also avoid the pitfalls
Acknowledge and praise success in peers’ achievements
Promote feelings of pride
Encourage storytelling
Jackson, D (2007). Personal resilience as a strategy for surviving and thriving in the face of workplace adversity:
A literature review. Journal of Advanced Nursing, 60(1), 1–9.
Compassion in healthcare?
Above all: speak up
• ‘If you don’t speak up when it matters, when
would it matter that you speak? The opposite
of courage is not cowardice, it is conformity.
Even a dead fish can go with the flow.’
THANK YOU
[email protected]