By Gary Evans, Medical Writer
Experts say workplace culture change — a critical issue in an era of pervasive burnout — must include leadership, but it often begins at the grassroots level with some simple but aggravating problem.
For example, a persistent computer glitch — frequent auto logout requiring password re-entry — finally culminated in a “rage ticket” send to IT by a normally calm and collected clinician.
“One day it happened, and it was just too much for me,” said Lakshmana Swamy, MD, MPH, a critical care clinician at Boston Medical Center. “I was screaming into the void: ‘Why is this interfering with my patient care?’”
Swamy described the situation, and the far-reaching changes it led to, in Orlando at the Institute for Healthcare Improvement’s 2019 National Forum on Quality Improvement in Health Care. The overall theme of the session was that healthcare workers too often are in their own silos, playing the “strong silent type,” showing little emotion and communicating at a minimum. The result can be a culture of distrust, where workers fear showing weakness, and rarely extend compassion to their colleagues.
In the process of rounding, Swamy would access an ICU computer to view data and scans, then talk to the patient and family in a process that took 20 to 30 minutes. When he returned to the computer to round with the next patient, he had been logged out and had to sign in again.
“It seems like such a small thing, but when you are in a busy ICU — there are sick people and you are being pulled in 10 different directions — typos happen,” he said. “Typos lead to getting locked out of the system, and this would happen at least every other week or so.”
Being locked out for mistyping information or password meant IT had to be called to rectify the situation. Finally, frustrated, Swamy filed the IT ticket expecting little more than a “sterile reply of ‘That’s just the way it is because of these reasons,’” he said. Instead, he received a phone call from Brian in IT, who was surprised because automatic logout was supposed to be set at one hour — not 15 minutes. The computer tech realized other hospital computers also were incorrectly set, and told Swamy a systemwide change was needed.
“This guy to me was like a superhero,” he said. “In 10 minutes, he finds the switch and flips it. This problem never happened again. Reducing login attempts isn’t as flashy as dropping mortality rates, but it makes a difference over time — how many people in the system who were using this software were logging in, getting locked out, and calling IT to use their valuable time to fix it.”
Beyond that was the realization the healthcare systems were operating in silos when someone figuratively down the hall was unaware of the problem, which the clinician saw as insurmountable, fixed it in minutes, he said.
“I really wanted to break down silos,” Swamy said. “I thought, ‘Why am I communicating with everyone through the chart? Why do I not know what other people are doing?’”
This thought spurred further action, made possible when an unrelated quality improvement effort led to medical residents filing more safety reports after patient incidents. These incidents were reported, but did not necessarily lead to immediate action and full communication between staff. Swamy and colleagues started a one-hour, monthly workshop open to all caregivers to discuss one of these patient safety incidents. This format proved critical when a major patient safety incident occurred that led to staff acrimony and blame, he said.
Hospital policy is that vital signs for patients on diuretics, which can lower blood pressure, should be checked more frequently. One patient’s vital signs were not checked for 16 hours, and the patient was admitted to the ICU.
“It wasn’t pretty,” Swamy said. “There was a lot of blaming going on. Everyone kind of felt someone else dropped the ball. The residents thought the nurses weren’t getting the vital signs; the nurses were saying ‘You didn’t highlight that this was important.’ We said, ‘Let’s use this case and bring it in to the workshop.’”
They brought in nursing, physicians, pharmacists, physical therapy — “whoever we could get,” he said. Participants were divided into small interdisciplinary groups to discuss the case. “These are people who normally barely communicate through the chart, and have no idea what the other person actually does,” he said.
In the ensuing conversations, they discovered a systems problem that contributed to the incident. The policy regarding checking vital signs was outdated, and did not account for the different nursing shifts.
“Nurses used to work standard eight-hour shifts at this hospital,” Swamy said. “That changed over time. Nurses are working all kinds of shifts, but the way we ordered [vital signs] had not [changed]. They can be ordered every eight hours, three times a day, or every shift. That used to all be the same thing, but now it means totally different things.”
The problem was solved in a manner amenable to the various disciplines. The workshop meeting has since become highly attended, in part due to the promise of pizza and candy, he said.
“People love it because it is about their actual work,” Swamy said. “Some of them told us ‘For the first time I felt like I had a voice in the work I do, in making changes and having that autonomy and control over my daily work.’”
A ‘Broken System,’ Limits of Resilience
Many tangible improvements have resulted from the workshop and other silo-busting efforts, he said. For example, a labyrinth of steps to transfer patients to the cardiac care unit created the impression among residents that cardiology was intentionally putting up barriers to transfer.
“That’s the kind of antagonism that broken systems produce,” he said. “When you chip away at these silos, you really start to see trust come back.”
If left up, silos and barriers in workflow can lead to a toxic culture among healthcare workers, many of whom may not know what challenges their colleagues in other departments are facing.
“When you don’t know what another person is doing, and something goes wrong, people assume the worst,” Swamy said. “They assume people are lazy, they are not smart, or they don’t work hard enough. None of that could be farther from the truth. You realize that when you are in a room talking to [colleagues].”
It is important to underscore that broken systems and silos were responsible for the conditions of anger, blaming, and ultimately profound misunderstandings among these workers. Yet, the answer to this problem too often is that workers must become more personally resilient, said Jessica Fried, MD, a resident in the diagnostic radiology program at the Hospital of the University of Pennsylvania. “Interventions to date have focused on activities that can address wellness, balance, and well-being,” she said.
While yoga, meditation, and mindfulness are valid approaches, the problem is that it places an enormous burden on the individual to see after his or her own well-being, she said.
“If you are burned out under this model, it is your fault,” Fried said. “You didn’t take enough time for mindfulness; you were not resilient enough. Victim-blaming is something we never want to do. It’s also really obvious that resilient people also get burned out and depressed. We must move beyond mindfulness and yoga. The burnout epidemic facing healthcare professionals requires major culture change.”
This often is expressed in the adage “Culture eats strategy for breakfast, lunch, and dinner,” she observed. “We also know that culture change is incredibly difficult.”
Burnout eventually degrades employee performance, manifesting as irritability and cynicism. In other professions, this behavior may be ignored or tolerated, but the stakes are too high in healthcare.
“Burnout in healthcare professionals matters because it can impact patient care,” Fried said. “If we don’t do something about the burnout epidemic in healthcare professionals, this could be a public health crisis.”
‘Culture of Silence’
A “culture of silence” often exists in healthcare settings that feeds and perpetuates burnout, normalizing perfection, and stigmatizing struggle and failure, Fried said.
“We were brought up in healthcare professions under a similar model of the strong, silent type,” she said. “Through both implicit and explicit professional modeling, we have learned to hide our struggles, failures, and mistakes. This creates a toxic work environment in which people must struggle and suffer in silence and isolation.”
Breaking this silence can begin at the individual level by asking colleagues how they are doing and speaking more openly about you own feelings, she said, urging interacting with co-workers with compassion and honesty.
“Take some time to say to your colleagues ‘How are you doing today?’ It really can make a difference,” Fried said. “If you feel tension in the room so thick you can cut it with a knife, face it and acknowledge it before moving on with your work. If you are having a terrible day, be open about it. If you are having a fantastic day, where you remember why you love doing your job, share that, too.”
These small gestures might seem trivial within the thicket of factors that contribute to burnout in the workplace, but healthcare workers can slowly create a culture in which emotional expression in the workplace is normalized, she added.
In addition to suffering in silence, healthcare workers will sacrifice their own well-being in the name of patient care, forgetting the IHI adage that “you cannot pour from an empty cup.”
“We sacrifice ourselves, thinking it will contribute to the greater good,” Fried said. “Coping with untenable work schedules and suboptimal work conditions by constantly sacrificing small but key elements of self-care perpetuates the burnout cycle.”
Instead of skipping breaks and coming to work sick, take as little as 10 minutes a day to focus on personal well-being, such as eating lunch away from the desk, celebrating small victories, and other things to help recharge.
“Many may feel that addressing burnout in their workplace requires tectonic changes that require buy-in from the C-suite,” Fried explained. “There are some issues that can only be addressed from the top down, but you have an incredible power to influence a successful workday for your colleagues.”
For example, Fried suggests telling colleagues at the end of a tough workday: “I see how much you care about what you do. I appreciate that.”
Emotional availability in this sense requires a certain level of “psychological safety.” IHI defines this as workers feeling comfortable enough to openly communicate without fear of repercussions. Such an environment — a “just culture” — enables learning, reduces risk, and builds camaraderie.
“Situational humility” can improve a culture of psychology safety, Swamy said, citing an example of a surgeon at a meeting with members of nursing and other disciplines who asked for input on a case, unexpectedly saying that he was not sure he made the right decision.
“That one statement changed everything. Suddenly, you had the interns, the nurses, everyone in the room asking questions,” he said. “If [the surgeon] could say that, then the rest of us could ask the questions that otherwise we might not have the psychological safety to ask.”
Fried made a similar effect by telling some medical school students that it is all right to be anxious about some of the challenges and that she experienced similar feelings.
“So often in heirarchical medicine, people really feel like they are expected to know all the answers,” Swamy said. “When you feel that inside, you show that outside. When you can crack that a little bit and say ‘I am not totally sure,’ it is not going to erode people’s high esteem for you.”
The IHI speakers underscored that a healthy work culture must be inclusive, going beyond clinicians to include housekeeping, food service workers, and other employees. Fried said she makes a point of interacting with all staff at the hospital as part of creating a healthy work culture.
“All of us owe it to ourselves to make sure that we are inclusive of our community as a whole,” she said. “Everyone makes this engine that we call healthcare run, and we need to all be part of that of together.”
By way of example, Swamy mentioned the story of Rana Awdish, MD, a physician who wrote a book about going into severe shock and receiving more comfort from patient transporters than clinicians. (For more on Awdish’s story, see the article in the August 2019 issue of Hospital Employee Health at: http://bit.ly/2RZWsR2.)
“There is a point where the only people who get her — and who get her back — are the patient transport workers,” he said. “They work together as this amazing community that she had never known about.”