There is a strong emphasis among individuals in society on two aspects; the first being materialistic. That if you earn a higher income, then you don’t have any other rights equal to the ones who earn less income because you are now in a position of privilege. The second aspect being socialist. That if you are in a higher position that allows you higher control over your environment, then again, you don’t have other rights equal to those who are less privileged in that sense. And according to social determinants of health [8], the higher the income, and the better control you have over your life, the better odds of a healthier outcome in life would be. So, it is “fair” to practice social redistribution of resources among individuals in society, be it moral or material. And this role is taken by institutions; governments, corporates, and/or other organizations, to reduce gaps and promote equality. [10][11][12] The calling behind this endeavor is “noble” (?)
However, if philanthropy or the welfare of all individuals is the intention of the healthcare institutions; collectively the system, is it also noble to mistreat healthcare providers because they are assumed to be “inherently” privileged? Does this approach balance society? Or is it creating more gaps, and inequity towards the previously mentioned and targeted healthcare professionals? Is stereotyping fair? Is it ethical?
I, as a pharmacist, have traveled many times to new places for work. Once I arrive at the new place, there is an immediate impression of holding and pushing things back, lack of support, an offensive demeanor, and/or a combination of them. This is not a coincidence, this is a repetitive phenomenon, a trend, tens of times. You are not expecting to be treated exquisitely special, but you need the tools to do your job, the right way, and you need your basic human rights as an individual to give a high percentage of your professional self, once again, to do your job. To care for your patients.
Is there prejudice and stereotyping? Absolutely. That if you’re in a higher position (higher income and social status) compared to other co-workers in your institution, therefore, you are privileged and you should be treated in a certain way, despite all your other unfortunate circumstances in life -if they present- they are given the deaf ear. And it is your responsibility to struggle and work harder than necessary. An unnecessary added stress that eventually builds up to Burn-out. Not even mentioning other forms of prejudice and discrimination, like racism, implicit and gender biases, both individual and institutional.
According to The House of Commons Standing Committee
on Health’s report, June 2019:
“Healthcare workers have a fourfold higher rate of workplace violence than any other profession. And yet, most of the violence experienced by health care workers goes unreported due to a culture of acceptance.”
“More broadly, the Committee heard that there is a culture of acceptance or
[1]
normalization of violence within the health care system that prevents change from occurring, as Ms. Margaret Keith Adjunct Faculty, Sociology Department, University of Windsor, articulated:
The culture of silence around the issue of violence is a major barrier to acknowledging its existence and consequently, addressing it. However, although the public has been kept in the dark about this issue, it is not a problem that is unknown within the healthcare community.”
There is workplace violence in the healthcare system, that everyone in the healthcare community knows about, but it is usually swept under the rug.
Workplace violence can include: [1]
- Psychological violence, which includes harassment, bullying, intimidation and demeaning treatment of a worker.
- Financial violence, which is defined as actions taken to prevent advancement or promotion of an individual, which may have a financial impact.
- Sexual harassment, which is a form of harassment that includes repeated unwanted sexual behaviour that has harmful consequences for the victim.
- Physical violence, which involves the use of physical force by a person against a worker in a workplace that causes or could cause physical injury.
“These statistics are just the tip of the iceberg in terms of understanding the rates of workplace violence facing health care workers across Canada because incidences of violence often go unreported due to fears of reprisal from employers.”
“workplace violence has an impact on the delivery of care, as it
[1]
results in staff shortages due to workplace injuries and high rates of burnout and workplace stress that affect quality of care and increase costs to the health care system.”
According to the Canadian Standards Association, January 2013:
“Psychological health and safety is embedded in the way people interact with one another on a daily basis, it is part of the way working conditions and management practices are structured. Bearing this in mind, mental health is a significant consideration across workplaces. The Canadian Mental Health Commission has reported that, in any given year, one in five people in Canada will experience a mental health problem or illness, with a cost to the economy well in excess of 50 billion dollars.”
[2]
Burn-out is not an individual problem, it is a community one. A global one.
According to WHO’s 11th Revision of the International Classification of Diseases (ICD-11), Burn-out is included as an occupational phenomenon. It is not classified as a medical condition.
“Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:
- feelings of energy depletion or exhaustion;
- increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and
- reduced professional efficacy.” [3]
The toll of Burn-out is taken up by the healthcare system, then it’s given back to institutions, through cuts and reduction of resources, and the vicious cycle continues. We need to stop this cycle.
In the modern era, a power structure, a.k.a., a hierarchical organization is not eliminated. But what’s happening is changing the way it functions. Observed attempts to move it from Status Hierarchy [14] to something else that reflects “equity” among members of the same organization? [14] But is this approach the right direction to achieve that?
In this new model, power is being moved from individuals to more dominant interest groups, a.k.a. administrations, and corporations. And what is happening within the organization itself, between the members, the moving parts of the organization, is the creation of informal to semi-formal Dominance Hierarchies; in which members of a social group interact, often aggressively, to create a ranking system [13]. So, what we have is, a hierarchy within a hierarchy. A dominance hierarchy within a power hierarchy. An example would be large chain pharmacies in which administration is the head of the hierarchy and the pharmacist, technicians, and assistants, a.k.a. the pharmacy team is within a dominance hierarchy. The example goes to hospitals and other healthcare organizations.
The aim of power groups (corporations) is to achieve “cost-effective” outcomes and reach their desired metrics. This is business-driven. They have “clear-cut ends” so the means are justified.
Business is an inevitable part of healthcare, but it shouldn’t be it’s core principle, whether hidden or announced.
The problem with this model, again, is moving power from individuals (healthcare providers) to interest business groups (corporations) that is more prone to manipulate the healthcare provider, and the patient-provider relationship, which is the most delicate part of the healthcare process. Individual power and autonomy in that sense should be nourished and empowered, not disrupted or taken away, for any other “non-therapeutic” claims, as seen on the ground.
Corporations’ claims and ways to treat teams as “equal” members in terms of distributing resources, is disrupting the provider-patient relationship, creating a dominance hierarchy within the team. [13]
“Dominance rank is often based on an individual’s reputation for fighting ability, and it can also be inherited. In social species that physically compete for material resources and social resources, dominance hierarchies are common”
[16]
It is no longer moving toward, who is more professionally qualified within the team. It is, who fights better for the rank to dominate, to earn the limited resources allocated by “head office”. Resources that are subject to change, usually in a dwindling manner rather than the opposite. Power should go back to the healthcare professional for various reasons, as highlighted in this researched article. And here is a suggested model of why healthcare teams should be like.
The Canadian Healthcare System is proud of its universality. Delivering healthcare to all Canadians, equally, regardless of who they are. This is social justice. But, at the same time, this system needs sustenance, and this sustenance allows it to give back to healthcare institutions. This influx of resources is not guaranteed, and it fluctuates all the time. The reduction of resources and continuous cuts put strains on healthcare institutions, and this, in turn, will be delivered to healthcare providers.
How?
Layoffs, understaffing /staff shortages, reduced salaries, reduced benefits, reduced administrative support, longer working hours, work overload … etc. Some or a combination of several of these factors and outcomes depending on each unique situation. This creates gaps, and these gaps are subject to be filled with increased workplace violence and burnout.
“In a society moving increasingly toward group action it may become impractical, in terms of allocation of resources, to deal with systems through their components. In many cases it would appear more sensible to transfer to the corporation the responsibility of policing itself, forcing it to take steps to ensure that the harm does not materialize through the conduct of the people within the organization. Rather than having the state monitor the activities of each person within the corporation. Which is costly and raises practical enforcement difficulties, it may be more efficient to force the corporation to do this, especially if sanctions imposed on the corporation can be translated into effective action at the individual level.”
[15]
“A new report from the Ontario Hospital Association says after decades of cuts, Ontario’s severely strained healthcare system is the most efficient in Canada and any further attempts to pare back frontline care may lead to reduced public access to vital services that are already at or over capacity.”
[4]
“Without exception, pharmacy across Canada is currently in an era of funding cuts, where any new source of revenue is likely to be offset by reductions. Provincial governments across the country are looking at the drug budget line as one that can easily be cut to find savings.”
[5]
When the Healthcare system run by the government receives a hit, healthcare institutions will receive that hit too. And eventually healthcare teams, and healthcare providers. It is a cycle, with multi-level contributing factors in between. But, what we know is, that Burn-Out is unnecessary, it is costly, it is a modifiable factor, and can be mitigated.
“ Health care employers consider violence an occupational health and
[1]
safety issue, but it needs to be considered a care issue. There is absolutely no hope for quality of care without considering worker safety. Having safe healthcare workers means better care.”
Here are seven barriers to implement workplace violence and harassment prevention by employers in Canada:
- Lack of action resulting from reporting. If nothing is
done or perceived to be done, employees will view
reporting as a waste of time and fail to report. - Varying perceptions of what constitutes violence.
Some staff view forms of violence as ‘part of the job’.
Others take into account the person’s intent behind
the violent act. - Bullying among co-workers. Increasing one’s
influence and reducing their accountability increases
the risk of bullying. The reporting system must hold all
individuals at any organizational level accountable. - Impact of money and profit-driven management
models. Profit-driven models may not apply in the
Canadian context, however, program costs may deter
leadership from large upfront investments. The dollar
impact of violence and harassment on other variables
such as turnover, absenteeism, medical errors,
productivity and litigation should be considered.
Small businesses with limited resources may find the
development and implementation of a comprehensive
program challenging. - Lack of leadership and management accountability.
There are many opportunities to ensure employees at
all levels of an organization are accountable for their
actions and decisions. Strategies include management
partnering with employee unions and employee
representation on committees and decision-making
groups. - Intense focus on customer service. The focus on
customer service often results in a mentality that the
customer (or patient or client) is always right. The
customer-service mentality can both result in no or
little action taken against an abusive customer
(including family members) and intimidation of staff,
to the extent that the organization is more permissive
about unacceptable behaviour. - Weak social service and law enforcement
approaches to mentally ill patients. Often hospital
care providers become default caregivers and
managers of patients with broader social problems
due to poorly funded or ineffective social services. [17]
A healthcare professional who spent years upon years refining their credentials, skills, and expertise is under ongoing attempts to strip away their professional identity, and the essence and the purpose of their calling, under so many claims, like political correctness, and social justice.
Evolving care, medical sciences and technologies, complex healthcare structures, In addition to other factors such as the aging population with increasingly complex needs [1] and more demands, shouldn’t be thrown at healthcare providers because they are “privileged”, they are human beings who are going above and beyond to adapt the evolving healthcare needs and fulfill their professional duties. To subject them into unnecessary and continuous struggle is not helping the society or the healthcare system. Quite the opposite.
“Results from the 2017 CMA National Physician Health Survey showed that 49% of residents and 33% of physicians screened positive for depression, and high burnout rates were reported in 38% of residents 29% of physicians.”
[6]
“The total cost of burnout for all physicians practicing in Canada is estimated to be $213.1 million ($185.2 million due to early retirement and $27.9 million due to reduced clinical hours)”
[7]
“advising physicians to take better care of themselves by exercising, doing yoga, and meditating to reduce stress seems vastly misplaced. As some have argued, this kind of approach completely ignores the systemic problem here, which is certainly real. Of course, there are some who argue that the “system” is really a scapegoat, that forcing physicians to pay more attention to metrics (which is probably necessary in an increasingly complex health care landscape) conflicts fundamentally with a medical culture that values autonomy and creativity.”
[9]
Research started by asking this critical question, I wasn't expecting an equally balanced answer, as such a phenomenon is vast to cover, nor was I expected the realization to be neutral since the issue itself is skewed in one extreme. But I have come to many conclusions examining my years of experience working in many different healthcare pharmacy settings, through introspection, scrutinization, and analysis of the emotional and psychological effects of these experiences. Then I researched the issue while extracting this article. It's been a journey that I learned a lot from.
References, Citations and Attributions:
[1]https://www.ourcommons.ca/Content/Committee/421/HESA/Reports/RP10589455/hesarp29/hesarp29-e.pdf
[3]https://www.who.int/mental_health/evidence/burn-out/en/
[4]https://www.cbc.ca/news/canada/london/ontario-hospitals-efficiency-healthcare-reform-1.5406753
[5]https://www.bcpharmacy.ca/news/pharmacy-canada-quick-look-pharmacy-funding-across-country
[7] Dewa, Carolyn & Jacobs, Philip & Thanh, Nguyen & Loong, Desmond. (2014). An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC health services research. 14. 254. 10.1186/1472-6963-14-254.
[8] http://www.simcoemuskokahealthstats.org/topics/determinants-of-health
[9]https://www.psychologytoday.com/ca/blog/denying-the-grave/201910/is-physician-burnout-unique
[11]http://research.allard.ubc.ca/social-justice-and-corporate-law/
[12]https://cna-aiic.ca/~/media/cna/page-content/pdf-fr/ethics_in_practice_april_2009_e.pdf
[13]https://en.wikipedia.org/wiki/Dominance_hierarchy
[15]Brent Fisse, John Braithwaite. Corporations, Crime and Accountability. Cambridge, UK: Cambridge University Press, 1993, p80.
[16] Francesca Giardini, Rafael Wittek. The Oxford Handbook of Gossip and Reputation. Oxford University Press, 2019, p280.
[18] William Weiner ACSW (1989) Is Burnout an Institutional Syndrome?, Loss, Grief & Care, 3:1-2, 95-100
