Flourishing on the Frontline

Editorial - Vicky Price & Michael Trimble 

All UK based doctors will be familiar with the GMC’s instruction to ‘make the care of your patient your first concern’.  Care is an interesting to word; it can mean to care for others or a degree of troubling anxiety, as in ‘worries and cares’. This ambiguity goes as far back as the word’s Latin origins in the 1^st century AD. ⁱ It is ironic in the setting of 21^st century health care to find that those who try to care for others are so burdened in their endeavours. Why should this be so? For most of us, from the day we enter medical school, and often long before, we hope to do something good, something to help people. At medical school and during training we are encouraged to ‘aspire to excellence.’ ⁱⁱ  But then in our working life we find that the systems and structures of our institutions do not allow us to do so. Instead of aspiring to excellence, we instead find ourselves working with the normalization of deviance.ⁱⁱⁱ This term was coined by sociologist Diane Vaughan when reviewing the Challenger space shuttle disaster. She used it to describe a situation where people within an organization become so accustomed to deviant behaviour that they don’t consider it as deviant; even though they far exceed their own rules for elementary safety. With safari ward rounds, patients in outlying wards, borders, and corridor beds now so routine practice as to be unremarkable, we are surely living with the normalization of deviance.  There is tension between how we wish to practice and how we actually practice.  Moral dilemmas arise when a caregiver must choose between incompatible courses of action, each of which has ethical justification; moral distress is the psychological impact which arises when the agent is clear about the ethically appropriate course of action, but institutional constraints make it difficult to implement. ^iv Beyond this is moral injury – the point is reached where individuals who are exposed to events that violate their moral values experience severe distress and even functional impairment.^v

Though less often discussed than individual or professional ethics, institutions too have their ethical attributes.^vi  Pellegrino and Thomasma contrast commercially driven health care systems with those based on fiduciary trust and note how this can influence the practice of the clinicians working within. ^vii We could add to these bureaucratic systems, with a focus on the achievement of certain targets and this is perhaps more representative of the UK situation.

What can we do to change this? Ideally, a change in working environment and practices is required. We need adequately staffed units with physical and functional capacity for the work that is to be done. The Society is lobbying for this at every opportunity. As his been highlighted in recent political debate the model of healthcare delivery needs to be reviewed. However, even with political will and a well thought out plan, this is a long-term matter. In the meantime, we must support each other.

So how can we help each other? Somebody reaching out with kindness and compassion can be essential. The most basic way of listening to someone with cup of tea may sound painfully old fashioned and British, but it is understated in the importance of allowing someone some time to help someone make sense of their feelings. As outlined above, when faced with these working conditions, individuals can face a wide range of emotions and may not even recognise they are struggling.

In a system where there is increasing numbers of patients in increasingly more areas with increasingly more paperwork and administration, time is one thing that is getting hard to find, but so important to allow ourselves and others. As leaders we should be providing a role model in listening to concerns and providing support whilst simultaneously continuing to raise these issues.

As well as looking at what is provided by the local trusts, some people prefer to seek help elsewhere.

Nationally the following organisations all provide support to staff are;

• BMA counselling and support services^viii

• NHS Practitioner Health (England only)^ix

• National Wellbeing hub (Scotland)^x

• Canopi (Wales)^xi

• MDTA Northern Ireland, medical and training agency, support services^xii

1 Encyclopedia of Bioethics. Revised edition. Edited by Warren Thomas Reich. 5 Volumes. New York: Simon & Schuster Macmillan, 1995. Pages 319-331.
2 Tooke, J. Aspiring to Excellence. Final Report of the Independent Inquiry into Modernising Medical Careers https://www.medschools.ac.uk/media/1934/aspiring-to-excellence.pdf
3 Price, MR. and Williams, TC. When Doing Wrong Feels So Right: Normalization of Deviance. Journal of Patient Safety 14(1):p 1-2, March 2018. | DOI: 10.1097/PTS.0000000000000157
4 Rorty, MV., Mills, AE., and Werhane, PH Institutional Practices, Ethics, and the Physician, in Rhodes, R., Francis, L. P., & Silvers, A. (Eds.). (2007). The blackwell guide to medical ethics. John Wiley & Sons
5 Griffin, B.J., Purcell, N., Burkman, K., Litz, B.T., Bryan, C.J., Schmitz, M., Villierme, C., Walsh, J. and Maguen, S. (2019), Moral Injury: An Integrative Review. JOURNAL OF TRAUMATIC STRESS, 32: 350-362. https://doi.org/10.1002/jts.22362
6 https://www.cambridge.org/core/services/aop-cambridge-core/content/view/BC197E7289B68C3169822D36890ED82D/S0963180100902032a.pdf/ethics-and-the-structures-of-healthcare.pdf
7 Pellegrino ED, Thomasma DC. For the patient’s good: the restoration of beneficence in health care, Oxford: Oxford University Press; 1988. p. 101
8 https://www.bma.org.uk/advice-and-support/your-wellbeing/wellbeing-support-services/counselling-and-peer-support-services
9 https://www.practitionerhealth.nhs.uk/
10 https://wellbeinghub.scot/
11 https://canopi.nhs.wales/
12 https://www.nimdta.gov.uk/professional-support-wellbeing/professional-support-wellbeing-contact-information/