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Physicians' Stress & Burnout During the COVID-19 Pandemic · Health Ethics Podcast

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Welcome to the COVID Ethics Series podcast, a conversation with leading experts about bioethical
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issues that have been exacerbated due to the COVID nineteen pandemic. I'm Brian Pilkington,
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and I teach bioethics at Seatonhole University and at the Hackensack Marine School of
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Medicine. I moderate the COVID Ethics Series in cooperation with the IHS Library and
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IHS Student Life. This podcast is a spinoff collaboration with the IHS Library where
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we'll have the opportunity to go deep with the experts from our series. Thanks
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for joining our conversation. Hello everyone, and welcome to the COVID Ethics Series
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podcast. My name is Brian Pilkington. I have the great pleasure today of
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speaking with doctor Nancy Berlinger. Most folks will know doctor Berlinger from our previous
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COVID Ethics Series episode, especially her really nice work in the session on vulnerability.
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So doctor Burlinger is a research scholar at the Hastings Center, again which
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your audience is familiar with, the independent bioethics research institute based in Garrison,
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New York. Her current research focuses on ethical and societal challenges arising from population
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aging, the bioethics of migration, and responding to and learning from the COVID
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nineteen pandemic. I'm going to pick up on that last one for our conversation
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today, But first, Nancy, welcome, Thank you so much for doing
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this. Thank you, Brian. I'm really excited to be here. This
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is always an interesting and thought provoking opportunity coming to Seaton Hall. Even over
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Zoom, you know, you feel like you know you're there, and I'm
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just over in Manhattan, so I can practically see you. So so you
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know, let's have at it. Excellent and if you and your colleagues have
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done some really interesting work on occupational stress COVID nineteen, so that's what our
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conversation will be about today. You have two pieces hospital physicians perspectives on occupational
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stress during COVID nineteen, a qualitative analysis from two cities recently published in the
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Journal of General Internal Medicine, and a second piece I think that's just out
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protecting practitioners and stress systems, which came out in Perspectives in Biology and Medicine.
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So let's start with the study and background that would be helpful. Take
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us through sort of the basic arguments and then we'll come back and ask about
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what motivated the project. Fantastic, Okay, So what you're seeing here are
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some of the publications from a study that is led by Mara Bookbinder, who
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is a medical anthropologist based in the Medical School at the University of North Carolina
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at Chapel Hill. She's a bioethicist and an empirical researcher. And our project
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does called Steps the Study to Examine Physicians Pandemic Stress. And I will share
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a link to the project website so you have that for your reference because that
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has complete information, links to publications and so on. And it's really two
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studies. One is funded by the Making a Difference Grand Program of the Greenwall
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Foundation. The other is funded by the National Institute on Occupational Safety and Health,
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which is part of CDC. So we're going to be having even more
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publications coming out of this together. It's a four city study looking at perspectives
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from frontline doctors who worked in hospitals during COVID in New York, New Orleans,
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Los Angeles, and also Miami. So the first set of publications mostly
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deals with the data from New York, and New Orleans, so it will
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be especially relevant to a seat in hall audience, I think because the New
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York and New Jersey were part of that same initial search. So some of
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the things we talk about, you will find a resident with your own experience
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of you yourself were a frontline clinician in the Greater New York area. So
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what we did was we were interviewing about forty physicians, attendings and fellows in
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each of the cities. We looked at five different specialties hospitalists, internis critical
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care specialist, pomonologists, palliative care, and emergency medicine physicians. So this
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is you know, when you think of the COVID frontline, these are the
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professions you often think of. We had to exclude residents and students for reasons
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that had to do with their status, their teaching status, and it was
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very important to be able to say that this was a person who was acting
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as a physician the entire time. Although it was interesting when people talked about
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ways in which they used willing students and residents as volunteers, not in clinical
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medicine, but maybe following up with families or doing it work and things like
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that. So what we were aiming to do, and these were there was
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a huge push to understand what was going on in real time, so you
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know, all credit to the funders who had to respond very quickly to what
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people were talking about. So what we wanted to do. We collected these
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data in twenty twenty one, and we wanted to look at how the occupational
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crisis of chronic stress and burnout that was facing doctors and other clinicians, which
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we all know predated the pandemic. Understaffing was a thing, burnout was a
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thing. This wasn't, you know, hugely a surprise, but what happened
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to it in the crucible of pandemic of public health emergency and what are the
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lessons going forward, not just for pandemic but for ordinary working conditions. So
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what we wanted were those insights from the front line, beyond the heroes and
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the clapping and you know, the free donuts and things like that. What
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could we learn from people on the frontline. So we recruited this large array
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of physicians, We did interviews with them over zoom, we analyzed our findings.
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We have a team of that includes social scientists, physicians, remarkable advisory
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group of clinicians nationwide, and then we are now synthesizing and sharing our findings,
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which as you mentioned in the Journal of General Internal Medicine Perspectives in Biology
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and Medicine. We also had a peace in the Annals of the American Thoracic
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Society. We've done a number of webinars and there's going to be more to
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come, and we're just about to release an executive summary that includes our recommendations
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for a key audience, so you're kind of getting a preview of that.
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So this is very this is perfect timing. So some of the things we
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learned from from the clinicians themselves were that clinician well being has physical, emotional,
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and moral dimensions, including the perception that one is able to do a
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good job, one is able to do well by one's patients. So for
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clinicians, the idea of my personal well being and my idea of my professional
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integrity is intertwined. You're not going to feel good about yourself if you felt
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like you did a lousy job at work unless you are very compartmentalized. For
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clinicians practicing in continuously changing work environments, which is typical in healthcare, it's
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not just a pandemic thing. Picture in an emergency room. It changes all
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the time. Discerning how to provide good care under inherently stressful conditions is both
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physically taxing and emotionally taxing. Picture a person who's comes off of a being
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on service in hospital medicine, somebody who comes off shift in the ED.
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They're tired, but emotionally it's been tough. They have heard all sorts of
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stories, respond to things in real time, lots of data. It's not
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easy. Now. When clinicians perceive themselves as unable to provide good care due
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to lack of resources or other factors, they do not control, it severely
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undermines their well being. It might even be corrosive to their well being.
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They might feel that here I am trying to advocate to the very system that
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I feel is causing the harm. I'm in an impossible bind here. And
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so these conditions that impede good care create what we call moral stress for clinicians.
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We didn't make up this term. The philosopher of healthcare, Alan crib
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uses this term. He's one of the great innovators of empirical bioethics, but
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he initially in studies on the National Health Service in the UK under austerity.
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He said, what happens when the system itself is grinding the clinicians down.
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So it's not just moral distress this case or that case, it's the conditions.
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Imagine a big screw turning on top of people when you see the pressure
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that working under these conditions is causing. And it's not something that you can
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fix on your own, and you certainly can't fix it by somebody telling you
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you should de breathe or do some yoga or something that might make you feel
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a little bit better. It's not going to change the conditions. So this
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kind of stress is pervasive, routine, deeply embedded in healthcare work, and
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isn't something that you can make go away. And even just talking about it
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doesn't make it go away. It isn't just a mental health problem, go
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get some counseling or something like that. It has to do with the conditions
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of work. So responding to moral stress in medicine and in other areas of
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healthcare, though our study was limited to doctors, requires system level thinking,
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system level solutions. So what we were doing when we set out on this
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study is we wanted to use this lens that Alan Cribb had described to examine
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this crisis of professional well being looking at pandemic conditions. But again, as
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I said, looking moving forward, you know, how can we help people
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in systems under stress that are, let's admit it, focused on making money,
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cutting costs and improving patient outcomes, but are not necessarily set up to
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create optimal work conditions for people. What could we learn from this? We
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knew from our data that access to mental health and wellness programs, even when
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those were available, were not the whole of the solution as perceived by the
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doctors we interviewed. They were interviewed in other things that were bubbling up during
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the pandemic, such as mistrust of healthcare information. How did you deal with
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that when people didn't trust you? But also things that were internal. So
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I'll stop there before I get to some of our recommendations and see if there
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was anything else based on what I said that you want to explore a little
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further. Nancy, super helpful. A couple of minor things and then maybe
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some big picture ones. We have a very diverse audience, folks from all
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walks of life who tune into the COVID ethics series, but we always face
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pay special attention to our nursing and health profession students hall and also our medical
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students of the Hagenzeg Writing School in Medicine for students. Just sort of quickly
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and you do this nice and the second piece, but could you explain empirical
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bioethics and connect it up to transitional bioethics, sorry, translational bioethics, right,
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just so they know what we're going through exactly, exactly, Okay.
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So empirical bioethics is the use of empirical methodologies like surveys, interviews, focus
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groups, many other methods that we associate with social science research, public health
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research, many other forms of research where we're collecting data to answer a question
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about values, what should we do question? Or here are the issues that
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keep me up at night. You can't just make an argument about them or
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change your perspective. You need to actually understand what's going on on the ground.
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So when we interview doctors to try to generate recommendations about what people in
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their systems should do to support this workforce, we're doing empirical bioethics. So
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it's just it's a term that just differentiates it from just purely conceptual work like
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what is the nature of moral you know, intuitions or something like that,
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which is important conceptualizing, but it isn't it doesn't. It keeps it very
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street ready, It keeps it real. You're you're listening to those voices and
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you're you're, but you're you're taking it through a lot of processes. The
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interviews alone, you could wind up with eighty different suggestions. If you talk
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to eighty different people. You have to then analyze it. You code it,
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You say, okay, what are these people talking about? Who emphasized
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what? You analyze it together with your team and also with your advisors,
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which include social scientists which include experts, and occupational health which include working doctors,
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working nurses who can give you that reality perspective, and then you synthesize
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it into recommendations going forward. What's a good course of action? Now,
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sometimes you might say, we need to understand this problem better, but we
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like to go beyond calling for more research, you know, just let's perpetuate
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the lives of researchers and to say what would be an opportunity for positive social
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change? How can we improve the lives of the people. We're talking about,
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how can we honor that. So when we also talk about socially engaged
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research, we talk about looking about the people who are the sources of your
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data as more than just places to get data from. You're trying to deliver
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value back to them. So I think the sense of being very true to
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our informants really animates this project. A lot of people on this project teach
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in medical schools, so that's important to them. They don't want this to
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just be a set of lessons. They want to say, we're trying to
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make things better by the time you hit the wards now. Translational bioethics translate.
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That's kind of a Translational is a term that often modifies other different things,
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but the idea of translational usually means you're taking insights from one field and
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you're making them more comprehensible to a different field. We often talk about translating
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for the public. For example, if you go to an NIH website,
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you'll see you can click into for professionals for patients. That's kind of a
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way of translating. You're saying, well, the patients don't always have to
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know the precise titration or the chemistry. They need to know, what are
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the symptoms I should the side effects I should look for? How will this
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make my life better? So that's a kind of translation that we do.
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But translational bioethics usually means you're taking something from a clinical sphere and making it
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more discernible to another audience. So I think in this particular and in that
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particular paper, what we are trying to do is take things from a pandemic
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context, from a place that obviously looks really stressful, and to say,
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going forward, how can we bring these findings into the mainstream of efforts to
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improve healthcare? QI has been a longstanding activity, and healthcare people are supposed
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to be involved in continuous quality improvement. How do we bring improvements to the
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work environment to bear on work to improve patient outcomes as well? Because you
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know, I think if you talk with any doctor, any nurse, they'll
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say, if I'm under severe stress and feeling I'm not doing a good job,
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how can that be good for patient outcomes? I can't magically make things
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great for a patient if I actually think I lack the tools and the resources
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to do my job properly, and thank you both super helpful and thinking about
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well makes a lot of sense. We're actually talking about this in the undergrad
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bioethics class the other day. The importance of trends two folks in different disciplines
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and different backgrounds, and the explanation of empirical bioethics, which we're talking about
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a different class folks who also listen. Is super helpful. Anything nicely connects
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up what you've written in the paper sort of highlighted the importance of social theory
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and the possibility of addressing big systems when we need to make change. So
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super helpful. Let's pick back through this, but let's jump to the recommendations.
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Okay, So here are I'm going to give you some a set of
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recommendations. But I want to also remind everyone that when you make a recommendation,
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you have to picture the person you're making the recommendation too, so they're
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not the recommendtion dation to the air or the recommendation. Well, if we
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don't have universal health care, nothing good can happen. Well, you could
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wait a long time in the United States for that to happen, and that's
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not realistic. I'm very realistic about things and to say, Okay, I
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love my colleague Matt Winnie at and your colleague Matt Winnie at the University of
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Colorado. He's a physician and a bioethicist and an expert on professionalism in healthcare.
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And he'll say, I'm a pragmatist who leans toward justice, and that's
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what I try to do. I try to be very realistic in my recommendations.
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Even though I'm not a clinician and I don't work in a hospital.
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I've spent a lot of time in clinical settings, and I've taught nurses at
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Yale, and I've served on a bioethics committee in the least healthy county in
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New York State for many many years. And it's also the poorest county New
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York City in the Bronx and a little shout out for the Bronx, And
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so keeping it very real is important to say what it really is. An
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odd implies can situation. Any recommendation has to be something that the person receiving
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the recommendation could actually do, and also that it doesn't silo them off from
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other good stuff that could be happening. It doesn't make them loading them up
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with things and saying, wait, there's this other person who they should be
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collaborating with and we should know that rather than say you have to do everything.
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So one group that we learned about through our advisory group, in fact,
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was the idea of chief wellness officers. This is something that some hospitals
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have instituted to keep an eye on the health and well being of their workforce.
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It tends to be you tend to find chief wellness officers in academic medical
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centers like Northwestern or Mayo or Stanford. Not quite clear how this role is
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working in say, public hospitals, you know, because somebody had to invest
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in this, somebody had to make this work, but it is. I
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was invited to give a talk to the Champions of Wellness summit. There's this
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big summit that they have, and there were thousands of people, literally,
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like four thousand people on that call. So not everybody has to have the
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title chief wellness officer to be a person who works in the wellness space.
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So I thought that was really interesting. And wellness and well being, you
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know, some people use one, some people use another, so I'm not
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worrying too much about that. So we realized that it was smart to think
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of that person or group in a hospital as the audience for our recommendation.
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So that's what we had in mind. So sometimes we're also thinking of unit
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level chiefs because a lot of people talked about how important, even if they
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felt kind of alienated from the system in which they worked, they felt that
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their chief heather back and so like, how can you strengthen that role as
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a mentor and as a as a convener. So now I'm going to just
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give you an example of some research insights. I'm going to connect them to
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where an example from the data, and then say, and how does this
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generate a recommendation going forward? So it gives you a little tiny like research
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workshop here. So the int that we got out of the data that people
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talked about a lot was that they and this is all the COVID context,
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that they had intensified feelings of powerlessness. They felt they were unable to do
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their jobs well due to medical uncertainty, inadequate family presence for patients, because
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of visitor restrictions. I have a dying patient here and there's no family and
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resource constraints, it was harder to do a good job. One doctor said,
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here's just a quote that you tend to bring when you write things things
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up, you tend to look for quotes that illustrate your point, and one
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said I had a crisis of confidence. I didn't know what to do for
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my patients. It was really interesting to hear some people say things like,
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look, I just passed my boards, so I know how to do things
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by the book. And during COVID, I was being told we'll throw out
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the rules. It's all new. I didn't know how to do that yet.
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You know where some of the more experienced physicians were like, Okay,
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I decided to go into the ED. I'm used to changing situations. It
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was easier for me to do this than I could see that it was for
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some other people. But I think this was a big reason why people felt,
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yeah, we really do have to keep students and medical residentis out of
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this. They have not had enough experience to not be overwhelmed by some of
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these situations. But even people who were well established could say, wow,
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this was really tough to pivot so quickly, so the recommendations how do we
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go from this? And rather than say wow, this was really tough to
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say, what should we do better? And you tend to write recommendations with
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an active verb at the beginning of this. So commit to learning from physicians
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about the institutional factors that impede their ability to provide good care. Ask them
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about what the system itself could do better. Don't just say wow, what
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did you do wrong? It's like, what could the system? Where did
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the system not have your back? And promote quality improvement research QI research on
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workplace conditions that impede good care. Saying QI is about patient care, but
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it's about the clinician's role in patient clare the clinician's own work environment. This
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has if you look at the really important research, like the checklist research on
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what prevented certain kinds of central line infections, it had a great deal to
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do with people feeling confident that they could do all of those things. They
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knew they knew the right way to do it, and all the resources were
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there, all the equipment was there. They didn't have to go looking for
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things. So that's really people are just saying the same thing. Another research
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insight was that compliance with institutional policies and processes that prevented or undermined good care
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evoked very strong emotional responses a lot of this centered on visitation policies that people
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felt they could see, Okay, we need to keep patients and families apart
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because we cannot risk infection. And we're talking about people were recalling what it
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was in March twenty twenty, like, I get that, but some policies.
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People said, okay, my hospital had a policy that said it could
23:07
be end of life only, and they said, as we began to know
23:11
more about how to treat COVID effectively, the policy seemed to perversely incentivize a
23:18
family to forego treatment so that this patient would be quote end of life comfort
23:25
care. And this doctor said, I actually advocated for a policy change and
23:30
was successful in that because I don't think that people writing the policy foresaw that
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we were seeing on the clinical floor the difference when people were actually able to
23:41
improve, and so we didn't want to say only people who are going to
23:45
die deserve family. These other folks were still very, very sick, and
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so that was something that a very astute physician said, wait, wait,
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there's a policy problem here. We also heard people saying things like well,
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it really helped that a lot of the bullshit went away, like the idea
24:03
of all of the like the projects that you never were sure what the point
24:07
was. They said, nobody asked me to document my productivity. It was
24:11
pretty obvious I was being very productive. So people were worried, like,
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how's that stuff going to creep back in? Like these these you know,
24:19
these these compliance things. We understand certain kind of compliance, but we don't
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We never got the meaning of some of these other things. So the recommendations
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would be to solicit frontline clinicians input when you're developing patient care policies and processes.
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Don't just drop the policy on the group that's meant to follow it without
24:38
getting their input all the way through to say, look, this is and
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I definitely hear this from nurses because nurse and this is from prior work.
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They'll say, well, if something doesn't work, we're going to feel like
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we have to work around it. It's not it doesn't match the field conditions.
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So that's something just really important to say. Even if you're like,
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oh no, it's going to be back to the drawing board, you should
25:00
be evolving the group who you expect to implement this, and also requesting feedback
25:07
from those chiefs regarding the impact of policy changes. To say, higher level,
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how's this working in your unit? When you're looking across all the people
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involved in a team, is this working or is this just getting in somebody's
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way. Another thing that people felt strongly about where just evidence of inequities.
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Sometimes people even felt complicit, They felt dirty in perpetuating injustice when institutional practices
25:33
reflected bias as or perceived that they reflected bias or seemed unfair in how resources
25:41
were allocated. Now, this is again not a brand new issue. Anybody
25:45
who treats undocumented immigrants, which is an issue I've studied for a long time,
25:49
feels this. They said, I've got two patients, they have the
25:53
same needs, it's the same medical standard, and I have to practice to
25:57
a substandard care in for one of these patients because they're uninsured and uninsurable.
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I do not feel good about this. This does not I cannot reconcile this.
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And so in the COVID context, some physicians were concerned that race based
26:15
diagnostic algorithms contributed to racial disparities because they said, these biases we worry about,
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we worry about biased data informing these algorithms. We know that certain people
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because of social inequalities come in with health disparities. We worry that the algorithm
26:33
is not recognizing this very well. And yet it was very difficult because if
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you had two people who were very very ill, it might be really hard
26:42
to make a judgment about who had a slightly better outcome and who was You
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know, it was very very for people, and we did have all the
26:52
research findings that we have by now. So this was people recall in twenty
26:56
twenty one, recalling twenty twenty they did not have lots of data to draw
27:00
on. Now we know that ninety percent of people who died of COVID were
27:07
older. We know that that was the single biggest risk factor, was being
27:11
older for various different reasons, it had COVID hit your system very hard.
27:15
But at the moment, people were trying to make judgments involving two different patients.
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So thegnition, the recommendation is that the chief wellness officer who's ever thinking
27:26
about these should recognize that feelings of complicity are corrosive to well being. If
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those feelings are present, all the mental health strategies in the world are not
27:37
going to overcome what people see as a systemic injustice. So it's going to
27:41
be very important to have those clinician perspectives in any institutional efforts to mitigate health
27:49
disparities. That should be some separate activity that is being carried out somewhere.
27:55
You need to basically say, well, these are the people who are saying
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this is injustice. How I see it now, Maybe this is This could
28:02
be a misperception in some cases, and the care standard is good, but
28:06
there it is important to hear that that clinical voice some patients, especially,
28:11
I think in the sample from New Orleans, because that we took that a
28:15
little bit later, and vaccines had already come in by that point, and
28:19
so people because because we had delta, we had omicrons. So people were
28:23
reacting when we were talking with them. They weren't just looking back. They
28:26
were saying, here's what's going on right now. We couldn't you know,
28:30
when you write a grant, you don't know what an epidemic is going to
28:33
do. You don't know what a pandemic's going what twists and turns are going
28:36
to be. And so we we had some of our informants talking about rising
28:40
mistrust often directed at clinicians that led to feelings of anger and frustration. Now,
28:47
before the pandemic, we heard a lot about incivility UH nurses being bullied
28:52
by family members. There there have been big efforts to to to to focus
28:57
on this, even also between professionals, but this was also something new.
29:04
So, you know, one doctor said, you know, I feel frustrated
29:07
and angry when patients just tell me that the thing that they have isn't real.
29:15
I mean, how can I treat them? And how can I even
29:17
do this work? It's so difficult. So going forward, we didn't want
29:22
to just call for more training. There's lots of training. We want to
29:26
acknowledge that mistrust is a societal phenomenon. It's going on throughout the United States,
29:30
questioning of institutions driven by media that is new and ever evolving. It
29:37
will continue to affect clinicians, encounters with patients and families. This does happen
29:42
in other countries as well. Although some countries where we look at systems that
29:47
we think, wow, they get really good outcomes, there's often higher trust
29:51
in public health authorities. So we can't magically create the conditions in Denmark,
29:56
for example, in part because we don't enjoy that level of trust. But
30:02
there are other countries where people say, yeah, we are not getting the
30:04
deference we used to get as professionals, but we are also just not being
30:08
trusted in part because people see the consequences of cost cutting and they know being
30:15
rushed out of the hospital and things like that. So there are other things
30:18
that people are Some of these experiences that people have had with hospitals are affecting
30:22
their individual patient encounters. So we want that audience that we're writing for to
30:27
contribute to wider institutional efforts to build trust with patient populations and to help frontline
30:34
clinicians respond to misinformation and with mistrust. This is something that has to be
30:40
going on. It's connected to DEI work, it's connected to equity work,
30:44
it's conted connected to translational writing for the public, things like that. It
30:49
isn't just something that is only isolated around wellness. And of course we heard
30:55
about workarounds my favorite topic of something that I've written about a lot, because
31:00
what you saw during a public health crisis was the clinicians improvising practices. They
31:06
were managing new or intensified workflow challenges and not surprisingly coming up with a fix
31:12
even if you knew it wasn't a magical solution tended to make you feel less
31:17
stressed, you felt more in control of the situation. And there was a
31:21
lot of this that was going on. I mean, some of our original
31:23
assumptions about intubation didn't weren't panning out. And then it was seen like,
31:29
wait, no, no, no, we should position some of these patients
31:30
differently, whatever their oxygen reading is, We shouldn't intubate everybody. Some people
31:36
are doing better in other ways of supporting their breathing. So there were and
31:41
then you'd get a new set of clinical guidelines based on what field conditions were.
31:48
One physician, for a non clinical example, worked with their hospital IT
31:52
staff to develop a system to track family contacts because you know, you had
31:56
all of these people, you need to be able to follow up with them.
32:01
They couldn't visit. They had critically ill family members and they couldn't visit,
32:06
so you wanted to get every bit of family information you could. But
32:09
then say, well, look, we've got willing doctors who don't have the
32:15
frontline skills. They're physicians, they know how to handle medical information, though,
32:22
so why don't we ask them to make the calls so they'll be able
32:27
to look at the chart, talk with the family member and give them updates,
32:31
and this proved to be really important. We heard many variations on this.
32:37
Another doctor said I made a job for myself. She was normally an
32:39
outpatient physician, but she said, we had these relatively young fellows and attendings
32:46
dealing with a volume of dying and death that they would never have experienced normally
32:52
at this stage in their careers. I could not also ask them to make
32:55
these phone calls. So I put together the big list of the patients who
33:02
were the most critically ill, and I said, I will make those phone
33:07
calls for you. And you know, it was very difficult because the volume
33:12
of mortality and morbidity was so high that sometimes I was letting a family know
33:15
about a death. And she really saw that as relieving, taking weight off
33:22
the younger front line. And so you heard a lot of people doing things
33:27
like this. This wasn't a typical procedure. It wasn't I am the doctor
33:31
responsible for your care there before, I must inform you. Because the volume
33:36
was too high, and also the experience was mismatched, so you saw people
33:40
with experience and more time stepping up. It was really remarkable. So One
33:46
of the things we want to do as a recommendation is because workarounds tend to
33:51
be improvised, unofficial, sometimes they're kept a bit secret. Is lift up
33:57
these what people were doing to solve problems. Recognize these practices that people use
34:04
to manage new or intensified workflow challenges. Study these practices and their outcomes as
34:09
potential sources of practice innovation. Every innovation starts as a departure from a standard.
34:15
We don't want to keep things secret. And when I've given various talks
34:17
about this at other hospitals, people have said, I worry that we're going
34:22
to lose our workaround knowledge, our practical knowledge, our frenesis, you know.
34:25
Aristotle talked about this, you know, But we don't want to just
34:29
drive that underground, because we figured out some things and let's study them properly
34:34
and let's talk about them. And finally, one other category that people talked
34:38
about was the community of practice. They said, my immediate colleagues, my
34:45
teams, my unit level relationships were a source of strength that sometimes offset the
34:52
harms of when we perceived our leaders being inattentive to our frontline needs. We're
34:59
like, there's a disconnect between the C suite and the frontline. But we've
35:02
got each other. We're here for each other, being tight knit. We've
35:07
heard examples like stepping outside and eating lunch together, little check ins. We're
35:14
very very important for people. So, you know, the recommendation is create
35:19
opportunities for clinicians to explore the causes of moral stress in their particular work environments,
35:25
what goes on in the ED, what goes on into the ICU,
35:29
so on, and to share those promising practices. Here's what helps us to
35:34
keep it together in our setting. How do we share those insights with other
35:39
teams, with other units, you know, and not everything that works in
35:44
the ICU is going to work in the ED, but there may be some
35:46
insights within a system that could be very helpful. And then and of course
35:52
we've also seen in some hospitals have invested in reflection rooms or places where people
35:59
can go and just chill. I happened to be in a hospital in the
36:04
New York area for another reason, but I'm seeing all this, these beautiful
36:08
posters about these these these reflection rooms where people can just go and relax,
36:14
and they're very peaceful, and there's music and the idea is is kind of
36:19
like a little a little oasis and then you step back out into it.
36:22
It's it's it's part, it's not hard to get to, it's right there,
36:27
and it's a little something. And it reminded me of our data because
36:30
one of our physicians was saying, you know, I kept thinking about this
36:36
the TV series Mash from the seventies and eighties where people would go on R
36:40
and R and they wanted to get ping pong tables and pizza ovens and things
36:45
like that, because I really had to tell people the solution for burnout is
36:50
not working more it's forced ressed. You know, it's I really need you
36:54
to come off the line. I really need you to just you know,
36:58
shoot pool or something, which is like how do I write the budget for
37:00
the pig pong table? Like who's going to give me that? You know?
37:04
But I honestly feel in my bones that's what people need. So I
37:07
thought that was quite interesting and some hospitals are trying to figure that out,
37:13
and we need to think about ways that leaders beyond the investments in spaces,
37:22
also to help unit leaders learn how to be mentors, to understand the nature
37:30
of the leadership role. To cultivate these unit level cultures of inclusion and well
37:35
being an advocacy rather than saying, oh, that person's a natural leader,
37:40
how do how do we help everybody step up into that role and also maybe
37:45
encouraging periodic forums for discussion between the frontline and hospital leadership. I have seen
37:51
this work. I've seen in the ethics committee that I'm on. I saw
37:54
a previous CEO rotate through all the committees and and just basically listen and like,
38:01
yeah, take complaints and things like that, and basically say, okay.
38:06
It did help that that this particular CEO had started in that hospital as
38:12
a resident and knew the system all the way through and and so there was
38:15
like a one of us kind of a feeling. But we don't want to
38:19
brand these as complaint sessions. You know, oh, here they're going to
38:22
gripe at me on and on and on there there. You know, could
38:25
be different in different hospitals, but let's make sure that leadership is encouraged.
38:31
Some people call it management by walking around to understand what is actually going on.
38:37
It isn't just about more blue ribbons and more and more. We've we've
38:42
we've we've opened more facilities, because that's a big thing in healthcare. You
38:45
know, a lot we see that all over the New York region. We
38:49
see lots of hospitals branding themselves as you know, we're now all of North
38:53
Jersey, or we're we're practically in Canada. We've gone so far north,
38:58
you know. And and that's a thing that's really important in the C suite.
39:01
You know, if you're not building your dying, but the front line
39:07
in their facility may be like, I don't see any of that flowing my
39:10
direction. I don't see it flowing toward my patients. So that's part of
39:14
fidelity, that's part of understanding inside of an institution that you need to tell
39:17
a coherent story about where this system is going. So those are you have
39:22
now just been given hot off. It's not even on the press, just
39:27
the first sneak preview of these recommendations that we will be releasing soon. So
39:32
I offer that to you and of course welcome any questions. Nancy, thank
39:37
you as always a masterclass in bioethics. And I'll have one short question as
39:44
to where you're going. But I know we're getting tight on time. But
39:46
for our audience, especially for our students. And this is quoting from Protecting
39:52
Practitioners and Stress Systems. You note that doing bioethics, you and your college
39:57
doing bioethics in twenty twenty two requires systems thinking and multidisciplinary collaboration to address the
40:04
multi dimensional and intersectional problems of our contemporary world. Of course, everyone should
40:09
read the pieces and we'll get the links up to sort of the other work
40:14
that's coming out. But oh my gosh, we've got workarounds. Right,
40:17
you've just touched on which is my favorite book of viewers. You know,
40:21
the twenty sixteen from Oxford are workarounds ethical. I forget the subtitle, which
40:25
is excellent. We've got a discussion of the importance of taking seriously feelings of
40:30
complicity, which can be corrosive to well being. How we can't do this
40:35
unless we have on the ground, lived experience information right in the big research
40:37
project you have connecting to clinician perspectives, concerns about mistrust. We've been a
40:44
Aristotle, right, we made my day. So there's so much here,
40:46
and I think it's such an excellent illustration of how empirical bioethics can be translated,
40:52
but also just how we should do bioethics now, so this was wonderful.
40:57
The question I'll get you out is and you might have already answered this
41:01
because this is really cutting edge, right, not even how off the press?
41:05
But what's next? Both for this project? What's your next project?
41:08
What can we look forward to after we read through this work? Okay,
41:13
well look for look for the public published version of this coming out from the
41:17
Hastings Center and u NC in early twenty twenty three. I'm going to share
41:24
the link to the project website where you can get links to every single thing,
41:29
so you'll you'll get that as well. And again the project is called
41:32
STEPS, so you'll see that as an acronym. And so they and the
41:37
work that is funded by Niosh continues in twenty twenty three, where so there
41:40
will be more publications based on our data from LA and from Miami. And
41:45
the audience there is is focused on occupational health learning. So they're in addition
41:51
to people who do think about well being, think about bioethics, think about
41:54
those things, we also have people who are looking at at health and safety
42:00
in the workplace. It's a very different audience, you know when you look
42:04
at their publications, like some of them are like hospitals, fisheries or something
42:08
like, wow, bad stuff can happen to you, you know, on
42:13
fishing boats. And so it's very practical about what are the risks of this
42:17
workplace. And it's been really interesting to have advisors who come from that world
42:22
and to learn about what's helpful. And I think so I think we're going
42:27
to be hearing a lot about different conferences and webinars and opportunities over the years,
42:30
So we'll definitely be pushing that stuff out as well. And I think
42:34
it's good for people in bioethics to know about this that to know that there
42:37
could be, you know, an occupational health research center in the place where
42:42
they're working that's interested in these issues. So that's great. And then in
42:46
terms of other things that are going on that people may be interested in,
42:50
I will also be sharing the website for Bioethics for Aging societies, because a
42:55
lot of my work focuses on the ethical and societ i consequences of population aging.
43:04
A lot of our work focuses on either dementia or on housing. So
43:07
we just released a huge report on housing equity that comes from COVID data.
43:13
We're having our last webinar on Thursday, December eighth, very exciting. Anybody
43:17
is welcome to attend and I'll send the links for the report in the executive
43:22
summary. We have a follow on project funded by the Greenwall Foundation that is
43:25
going to be looking at trying to cut some of these Gordian knots in policy,
43:30
with a lot of policy makers that are involved saying why can't we build
43:34
the housing we need in an aging society? What's this about? And so
43:38
my mother is eighty eight and lives in Bergen County, so I see this
43:43
every day. You know, we built the suburbs that people moved to in
43:45
the fifties and sixties and seventies. We have millions of people aging in place
43:51
in these places, and we don't have the right kind of affordable, accessible
43:54
housing that people need. And meanwhile, these are people who've been paying taxes
44:00
to support school systems for you know, sixty years, so they have paid
44:06
into that system in addition to Medicare and social security. So bringing that into
44:09
bioethics is a passion of mine. We also have a project also funded by
44:15
the Greenwall Foundation, another shout out to them, called Bioethics and Community Health
44:21
This is a collaboration with my Hastings Center colleague, Carolyn Nuhouse, who's a
44:24
philosopher, and with our colleague at Albity Medical College, Johannah Crane, who's
44:30
a medical anthropologist, and they conceptualize a group of projects that work with federally
44:36
qualified health centers, which are primary healthcare clinics for people who face barriers to
44:42
healthcare, very frequently led by nurses, nurse practitioners, lots of social workers,
44:46
lots of community health also lots of physicians and pas, but nurses are
44:51
very prominent in FQHCs, very exciting to work with them. This is the,
44:55
I believe, the fourth project that we're working on, and we want
45:00
to answer, through surveys and interviews, the question what keeps community health providers
45:07
up at night? Because that's how we're framing the idea of ethical challenges.
45:10
We're not saying, tell me about your bedside deliberations. There's no bedside,
45:15
no sleepover in the FQHC. But that doesn't mean this isn't a morally complex
45:22
environment. So this is going to be a big, interesting project. We're
45:25
at the beginning of it. We have a lovely website that talks about all
45:29
of our work in community health and immigrant health, because immigrants are a major
45:32
population in community health. And yeah, we definitely want to hear from people
45:37
who are interested in this kind of work. So you're going to get Oh
45:42
and one more thing I want to tell you about. We have a project
45:45
from the National funded by the National Endowment of the Humanities called The Meanings of
45:50
Dementia. This is producing a volume of new essays about what dementia means in
45:58
aging societies. It's at its beginning phases. We have a very very diverse
46:02
group of authors. Look for that coming out probably in twenty twenty four.
46:07
But that's another interesting thing that's underway right now. Again not just about a
46:14
person who lacks capacity, but about the lived experience of dementia, which has
46:19
a long trajectory and has mostly lived in the home and the community. What
46:22
does this mean for societies? Does our vision of a good society include people
46:30
living with dementia and people who are providing dementia care. I now have my
46:36
reading list for the next couple of months. That's wonderful And it's actually just
46:40
before chatting, I was teaching class with my wonderful colleagues in the College of
46:45
Nursing on dimension these considerations, so I know they will be super interested.
46:50
I don't like to make sure they look out for twenty twenty four. So
46:52
great, Tonanzy, thank you so much for the time today. Thanks to
46:55
everyone for tuning into the covid Ethics Series podcast with Nancy Burlinger Research Dollar at
47:00
the Hasting Center. Nancy, it's always great to chat with me. Thank
47:04
you so much. Thank you, Brian, thank you everybody. This is
47:07
great. Thank you for listening to this episode of the covid Ethics Series podcast.
47:15
Be sure to check out video versions of our episodes online at library Shoe
47:20
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