Working in healthcare is challenging. We spend all day every day soaking up the sorrow of others. Far too often, we neglect to take the time to practice self-care. What is even more challenging is when we are faced with personal adversity, we are so driven by our compassion for others that the concept of self-compassion is regularly dismissed or pushed aside for more aspirational goals.
During our AMS-Phoenix sponsored work, we explored a model for reducing stigma towards individuals with mental illness by providing feedback to physicians and nurses about their implicit attitudes. We learned many things from the perspectives of patients and caregivers, but we also heard about the human side of health care professionals. Well-intentioned physicians and nurses gradually begin feeling less effective and without being aware of their behaviour, can often avoid certain patients, setting up a cycle of stigma and frustration that perpetuates itself. During our research, we found that when confronted with feedback about their implicit bias, health professionals had difficulty processing and integrating in this information.
Implicit bias refers to the associations and biases that exist within us but outside of our conscious awareness. Implicit biases can be both negative or positive and can be both helpful and dangerous. Negative implicit biases regarding individuals with mental illness can be described as implicit stigma.
Biases towards individuals and groups are universal because our brains are programmed to make associations with experience and time. One of the most common associations with mental illness is that individuals who are suffering are not sick, but rather demonstrate a weakness or deficit. This attitude or belief can be both conscious and unconscious, but is almost always dangerous. The belief that individuals who suffer are flawed can lead to blaming and shaming experiences that are internalized and have disastrous consequences. For example, over time, individuals with mental illness lose trust in a healthcare system that makes them feel like their illness is their fault. Our AMS-Phoenix sponsored work seeks to understand this challenge and develop and evaluate curricula to reduce stigmatizing experiences.
A serendipitous discovery from our work was that health care professionals could manage their biases better by acknowledging their humanity and imperfections. The first step involved recognizing ones’ own biases. This information leads to tension which is immediately acknowledged and explicitly addressed by reminding learners that we all have biases because bias is an inherently human attribute. Starting with a safe and non-threatening learning environment, we engage in discussion and dialogue and acknowledge so that learners realize they are not alone and many others might share these biases. Together, by questioning assumptions and making a conscious effort to change their behaviour, our participants began describing increased confidence in their approach.
Among the many implications of our work was our discovery of how teaching and learning about implicit bias relates to self-care and self-compassion. We are discovering that recognizing and managing bias requires letting go of guilt and shifting towards a sense of shared responsibility.
For example, one of my favourite authors Brene Brown writes in her book “The Gifts of Imperfection” that letting go of who we think we are supposed to be and embracing who we are can have far reaching benefits. She lists 10 “guideposts” for “wholehearted living” including guidepost 2: “cultivating self-compassion by letting go of perfectionism.”
Perhaps our culture within healthcare is unique among others because of how regularly we emphasize excellence and rationalize that pursuing perfection is necessary because of the human cost of error. After all, we would not want a physician or nurse to be flawed or imperfect when these flaws may result in poor outcomes, right?
Despite our efforts to produce high quality patient care, I would argue that our line of thinking is problematic. Humans make mistakes. We learn from these mistakes. If we are too hard on ourselves as health care professionals then the real-world consequences of our culture of perfection will result in an erosion of empathy, burnout, compassion-fatigue and ultimately poor relationships between patients and professionals. Nowhere is this process more evident than with individuals with mental illness and acute care settings where despite their best intentions, physicians and nurses feel overwhelmed practicing within a poorly resourced and hyper fragmented mental health system.
Achieving a balance between imperfection and the quality is a difficult endeavor for a culture that places excellence at the core of its very existence.
In such an environment, the suggestion that a physician or nurse needs to rest or take care of themselves can become associated with weakness. Rarely if ever will a physician or nurse openly share that they need help or are struggling with their own mental health difficulties. Indeed, despite all our work on reducing stigma towards patients, some of the most dangerous stigma in healthcare is towards ourselves.
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