It’s time to recognise and fix structural unkindness

“PANDEMIC” was the 2020 word of the year according to the Merriam–Webster dictionary. It’s no wonder, as the COVID-19 global pandemic has changed our whole society and exposed some of the darker aspects of human nature.

There is now well established research that demonstrates that the pandemic has exaggerated and amplified the pre-existing structural bias and systemic inequities in the health system.

Many of the structural drivers of health-related behaviours and outcomes such as racism have been extensively characterised, including the ways that the COVID-19 pandemic has exacerbated these drivers. But far less attention has been paid to the role of organisational and systemic factors relating to kindness.

The COVID-19 pandemic exposed an uncomfortable truth on the issue of kindness in health. Health care workers significantly experienced more COVID-19-related bullying than people who did not work in health care settings after controlling for the effect of confounders, found a study from 173 countries.

Another study from the US found that more than one-third of registered nurses experienced greater incivility at work during the COVID-19 outbreak than before the pandemic (37.4%), and almost half (45.7%) said they witnessed more incivility than before the pandemic.

And in Australia, 35% of medical trainees in 2021 reported that they had experienced and/or witnessed bullying, harassment and/or discrimination (including racism) during their training. These recent reports of increased incivility and bullying behaviour provide evidence that the pandemic may have exposed the lack of kindness in health.

I wrote two articles about kindness previously in Insight+, the first in 2015 titled Bring back care, where I stated, somewhat naively: “we should always have time to show our patients we do care. It won’t cost us much — maybe a quick smile, a caring touch, an extra minute to ask how they are going — rather than just focusing on their disease or illness.”

The second, in 2016, titled Kindness in medicine more than skin-deep, where I then stated: “As doctors and health practitioners, let us not just act kind, let us also be kind. As doctors, we can learn the technical skills and knowledge and try to apply this to the actions of kindness, but it is important that the actions are grounded by feelings of empathy and compassion, lest they come across as artificial or forced.”

In both articles, I laid the responsibility for being kind on the individual clinician – something that most proponents of kindness in health do.

But is that the answer – telling the health care workers experiencing unkindness, the nurses and junior doctors, to learn to be more kind? Do we tell them to learn to be more resilient and teach them coping techniques, and time management skills? There is definitely a place for individual training, and even organisation-wide training programs about compassion and care, and basic courtesy and manners.

But the issue is broader than just the individuals involved.

The COVID-19 pandemic has led to a health workforce crisis, with an unprecedented number of health care workers off sick with infection, or isolated because of being exposed as a close contact. The threat of infection, extra workload pressures, and exposure to the emotional trauma from the deaths of patients and colleagues, has led to a high prevalence of mental health disorders such as anxiety and depression in health care workers. This has in turn led to an exodus of clinicians leaving the health system for less stressful, better paying jobs in other industries, which has created a vicious cycle leading to a strained health care system.

It is no wonder that our health care workers are experiencing high levels of stress and burnout due to physical and mental exhaustion. Instead of just running wellbeing programs that put pressure on already stressed individuals to fix themselves, true wellness requires organisation-level interventions and systemic changes.

What do I mean by this?

In 1973, American psychologists carried out the now famous “Good Samaritan” study at a religious seminary, which found that people who had less time available and were in a hurry were less likely to help and be kind to others. This applied to religious people studying at the seminary who, as part of the psychology experiment, were ironically on their way to speak on the parable of the Good Samaritan (which is all about being kind to strangers), with some of them in the experiment literally stepping over the victim on their way to the next building.

This study tells us that even good people, who in their hearts know that they need to be kind to strangers, can skip expressing kindness if they perceive they don’t have enough time to do so.

The first systemic problem we have in health care is that we are not structuring enough time for our clinicians to be kind to each other and to their patients. Our schedules are designed to maximise efficiencies and minimise cost. We roster health care workers to reduce overtime and increase productivity. There is no time for kindness in our timetables.

In health care, we are perpetually in a hurry to go somewhere else, to do something else. This issue has been exacerbated by the arrival of the pandemic, which took out many health care workers from rosters, forcing the remainder to work extra shifts and overtime. Our people feel so stretched and squeezed by the system that it is not surprising that they feel that they have nothing left to give.

Despite the high workload and pressure, health care workers continue to turn up to work, to practise their craft and serve their patients. As leaders and managers of health systems, we have an imperative to ensure that the administrative and support systems are designed in such a way that facilitates the function of frontline clinicians, and does not impede or frustrate them.

We need to ensure that our already stressed clinical workforce are paid on time, get the IT support that they need when they need it, and receive the right equipment at the right time to carry out their duties. Our health care workers need to feel valued and respected for the sacrifices they have made on our behalf, especially when many have gone beyond the call of duty during these extraordinary times.

This means that we may have to pay some of our lowest paid health workers more adequately, such as those in our aged care system.

We cannot expect our clinicians to be kind to our patients and to one another if the health system itself is not perceived to be kind to them in the first place.

The first step is to acknowledge that structural unkindness exists in health, just like structural bias and racism. Our health system is currently designed to optimise cost and operational efficiencies above other metrics. Although well intentioned, this has led to the unintended consequences of having systems and processes in place that can be perceived as unkind and disrespectful by those who work within the system.

We should continue to promote acts of individual kindness and teach our health care workers to be compassionate, but we cannot stop there. We must also address the issue of structural unkindness in health, by carrying out further research in this area, and redesigning the health system so that it is seen as kind to those who work within it, so that they can be kind to others as a result.

Professor Erwin Loh is Group Medical Officer and Group General Manager of Clinical Governance at St Vincent’s Health Australia.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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