A stressful balancing act for managers

Healthcare managers’ lives involved a stressful balancing act, recognising the workload and stress on their staff on the one hand and trying to balance that with the amount of support and control they could put in place on the other, Professor Jim Lucey, Medical Director at St. Patrick’s Mental Health Services and Clinical Professor of Psychiatry at TCD, told the Conference.

Prof Jim Lucey
Prof Jim Lucey

“Our duty is to maintain as much of the capital we have in terms of our staff (and its mental capital) over the course of a career and over the course of a life. We must do this by re-balancing the resources we have with the burdens that are upon our staff.”

Prof. Lucey said organisational tensions within the health service were not new.

“The challenge to achieve legitimacy of our mission and vision, coherence of our clinical and financial delivery, and governance of our quality and services is always present. These tensions cannot be denied and they are actually the business of our day, just as they would be in any other business.

We have a problem in our Irish health services and, like any other functional organisational problem, it’s better acknowledge it rather than deny it.

“We have a problem in our Irish health services and, like any other functional organisational problem, it’s better acknowledge it rather than deny it. Ireland is ranked 15th out of the 17 richest countries in terms of healthcare outcomes. All of us are doing our very best and we have great hopes for our health services. We invest enormous amounts of our national wealth in it and it employs a substantial number of our people and a substantial number of our people depend on it. So a ranking this low is certainly disappointing.

“On the other hand, I think it is good that we are acknowledging the problem of variation and that we are seeing greater analysis of this kind of outcome. The reality is that there is significant variance in our hospital death rate. The results of studies looking at the in-hospital mortality within 30 days of admission for a heart attack, between 2011 and 2013, show a 3 to 4 point variation across centres.

“There are many complicating factors that could explain this variation but in a service such as ours standardisation of outcome and the achievement of the best outcomes is surely somewhere we need to go.

Prof. Lucey said a willingness to address human factors involved in areas where problems developed could require cultural change. Unfortunately the depiction of the culture of the Irish health services was not positive.

“Charles O’Reilly in Stanford saw issues of resistance to change as being cultural as well. He described inflexibilities, certain work norms, presence or absence of consensus and enthusiasms or a lack of them as being central to a culture that led to organisational failure. O’Reilly proposed that organisations in industry that continue to succeed were likely to be flexible or as he put it ‘ambidextrous’. They have ability to change.

“So the idea of leadership and management and their balance is crucial. The much lamented Prof. Aidan Halligan put it well when he said ‘leadership is about doing the right thing on a difficult day’. The truth is that a difficult day happens every day. It is a difficult day for a patient, it is a difficult day for someone’s family and leadership is about doing the right things on that difficult day for every patient in difficulties. This is an insight that you can only have if you have really been there, and it doesn’t really apply to many other industries in the same way.

“Of course we could resist that kind of insight and simply insist on a command and control approach to management and leadership. This kind of leadership leads inevitably to people looking after themselves rather than having any other purpose. When we think we are in command and control we are actually neither. This is an important lesson that healthcare managers have to learn.

“Healthcare can’t wait. The demands won’t wait. It is something that will not go away and it will always be political. Still the nature of healthcare demand is something that is changing in terms of social and political determinants. Nowadays the amount of need for care is dwarfed by the vast expanse of need for chronic condition management, of healthcare and wellness programmes and preventative care that exist in the community as a whole.

“It is also important to look at the changing culture of our clinicians. It is changing with the lifestyle of our doctors and our nurses and our therapists and our teams. We have to understand the young people go to college and they don’t change just because they get a degree or a certificate or a new white coat. Wellness issues exist in young people who take on clinical roles just as they do elsewhere. We need to understand that the prevalence of suicide amongst doctors for example is probably three times the background rate. It is not possible to dismiss the risk factors for clinicians by assuming that these people are different from the rest of society. The prevalence of cannabis use and of alcohol abuse are very common amongst young people and so will be common amongst our young staff.

If we look at the staff quality of life continuum as it relates to professional behaviour we see that there is a difference between distressed staff and well staff.

“If you look at the guidelines of the Medical Council, eight domains of good professional practice contributing to these things are described. Two of these, clinical skills and scholarship I would suggest are well catered for in their training and education, but the other six are not. They include intangibles such as professionalism, management including self-management, the relationship to patients, communication and interpersonal skills and collaboration and team work. These ‘difficult to define’ concepts are actually the ones that bring most clinicians to crisis point and they are the ones that impact perhaps most commonly on patient experience. It is these factors that we need to look at if we are going to have a fuller understanding of the management of our health service personnel.

“You might ask why any of this matters to a healthcare manager and it is a reasonable question. The reason clinician wellbeing really matters to the healthcare manager is because clinician wellbeing really matters to patient care. We know if we look at the staff quality of life continuum as it relates to professional behaviour we see that there is a difference between distressed staff and well staff. Distressed clinicians focus on themselves and they have reduced empathy. Well staff focus on the patient and they have increased empathy. Distressed staff have reduced compassion with more medical errors, poorer communication, less satisfaction at work and a higher prevalence of depression and substance misuse. Well staff are able to have compassion. Their quality of care is high; they have enhanced communication and greater satisfaction at work.

“We could also promote wellbeing if we had a common understanding of what wellbeing might be. My favourite understanding of wellness comes from the work of the New Economic Forum which describes ‘five ways to wellbeing’. They are to connect, be active, take notice, and keep learning and give. These five ways are characteristics of those who have wellbeing but they are also activities we could use to fill our lives.

”Burnout isn’t inevitable. It could be something that we as clinicians and as managers could look to prevent for ourselves, but as managers we must promote an environment where it is actually addressed. This involves introducing choice and making sure that the balance between stress and satisfaction is not unfavourable and so burnout is not inevitable.

“This leadership also involves promoting a concept known as ‘resilience’. There are six domains of resilience which we could look at. These are education, a secure base, social competences, friendships, talents and interests and of course positive values. All contribute to resilience.

“The resilient way forward is through teamwork and that involves all of us. We need to work together. We need to find models where this is possible.”