Picture this. A patient in a hospital or rehab facility has just finished exercising with therapy. He is thirsty, and he thinks he might as well ask for a snack now because he will be hungry in 30 minutes. His therapist sets him up in his wheelchair (brakes locked), tray table with all necessities positioned in front of him, with his call bell within reach. As she approaches the door to leave, she turns and asks, “Is there anything else I can do for you?” The patient nods and asks for a refill of his water cup and some peanut butter crackers. The therapist grimaces. What should she do?
To a sane person who doesn’t work in health care, this is not an obvious moment of ethical dilemma. Just go get the water and the crackers. It might take two minutes round trip. Maybe three if the therapist stops to talk to a nurse. Patient satisfaction is achieved, the therapeutic alliance is strengthened, nutrition and hydration are achieved, and besides, why would the therapist have asked in the first place if she didn’t want to help?
The problem is that health care is a business, and people in charge want to “optimize” employees as though they are components of an assembly line. Each staff member should be utilized to their highest degree only, and there should be just enough staff to do the job without excess expenditure. This might seem like sound business practice until you actually go through the experience.
In the eyes of health care as an optimized business, a therapist should not be getting snacks and water. That task is not skilled therapy, can’t be billed, and could be done by anyone. So, therapists are instructed to increase their “productivity” ratios in therapy team meetings by politely refusing this request. Therapists should offer to press a patient’s call button instead and then leave the room to do actual therapy instead of water retrieval.
But, nursing is also part of the business, and they are being optimized too. They are counseled to turn off any call light as soon as possible, partly because the time to call light response is measured and partly because emergencies can be detected faster if every call light in the facility isn’t blinking at once. So, the very busy nurse or nursing assistant races in to turn off the call light even though he is in the middle of helping someone else and can’t grab the water or snack right that moment. The patient has been asked what he needs by multiple providers now, and multiple providers have declined to meet that very basic need. But each provider has been counseled to act this way by their respective managers, all in the name of optimizing time and metrics, none of which measure whether the patient ever receives fresh water to drink after therapy.
In the book Compassionomics, the authors share a fascinating research study about helping behavior. People in seminary school were told that they needed to go to another building – either to give a talk about seminary jobs or to give a talk about the Good Samaritan Bible story. Some seminary students were given instructions just to head over, and some were given instructions to hurry over because they were already a few minutes late. Each student encountered a man slumped over in the hallway on the way to his talk. Interestingly, students in the hurry-up scenario only helped 10 percent of the time – even when they were going to give a talk about helping behaviors in the Good Samaritan story! Students in the control group helped 60 percent of the time. The researchers did note that many students who did not stop to help did appear agitated when they arrived at their destinations.
This study on helping behaviors is directly applicable to the above clinical scenario. Much like potential clergy, health care workers have a real heart for people. We want to help people in pain and who need help. We know intuitively that people who are treated with kindness and understanding get better than people who are treated by someone who stares at a computer screen and never looks up. We also know this concretely through research.
But, there is a pervasive culture of time constraints in health care. With staffing levels “optimized” to provide just enough patient care, and appointments scheduled close enough together to maximize profits, and (in therapy at least) reimbursement tied to time-based billing codes, as well as an ever-growing list of documentation/administrative requirements, we all feel pressured for time. Every single player in the health system is a seminary student given a warning not to be late to give a talk about helping behaviors. We have patients in the waiting room, documentation waiting for us at home after a long day of work, and productivity requirements hanging over our heads (and often tied to our paycheck). It’s basically in the job description to do as much as possible in as little time and not “waste” any minute on the clock. The health care system that we work in is priming us not to be compassionate.
This does not result in good care. The patient in our above scenario might wait for two hours for his glass of water and peanut butter crackers. Cynically, I sometimes believe that health systems hope for that because then the patient’s family member might come and sit with them during the day, taking care of these less medical but no less important tasks at zero cost to the health system. Unfortunately, the result of this time-crunched system is providers who face an ethical dilemma every time a patient makes a reasonable request that falls outside of the provider’s very limited scope.
In reality, no one is unqualified to get a glass of water and some snack from the nurse’s station. But in this health care world that sees providers as tools for production instead of humans employed to help other humans, anyone over qualified to pour water is encouraged not to do it. Providers want to help but are sandwiched in between too many patients and too many overhead pressures to be efficient. Much like the agitated seminary students who did not help someone in need, providers who feel they have to say no to reasonable requests and bids for connection in the name of “productivity” experience burnout, moral injury, and compassion frustration.
I want to emphasize that messaging around time constraints impacts helping behavior. If giving people an imaginary time constraint effectively extinguishes their helping behaviors, and our whole system is based around the idea that no one has enough time to complete their jobs, how can we expect people to provide compassionate care (or at the very least have good patient satisfaction)? Even if time constraints in the system don’t change, management can still dial back the “hurry up” messaging and productivity shaming. This will decrease the conflict providers feel when they want to respond with compassion, improve patient care and satisfaction, and improve employee retention.
Hannah Todd is a physical therapist.
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