We need a more realistic approach to implementation in healthcare (Part 2)

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by Kristian Hudson

Traumatised systems, traumatised people

There are a lot of people post Covid, and a lot of practitioners who are traumatised. In my field of work this was most evident on ICU wards. There is also the idea of traumatised systems. Data has shown how hard these systems were before Covid and the moral injury that practitioners experience in the service settings. Unfortunately, there’s just not enough in the literature and the big implementation science journals and conferences which talk about these burnouts and these traumas.

If we are going to be increasingly involving people in the research we do and creating teams with multiple stakeholders, we need to think increasingly about psychological safety, and as a result implementation researchers need to skill up. We need to skill up on the measures and ways we can create psychological safety but also know how to measure it, so we know if we are doing any harm or not. Because we don’t want to bring people in on teams who then don’t feel safe being on that team. Our methods also have to shift if we are going to authentically be participatory. 

Turnover is now also a problem. Many healthcare systems can see as much as 60% a year turnover for direct service staff. Now post Covid we are seeing large cities that although had a problem with turnover in their systems before, now have a recruitment issue. Before Covid there were people that could replace those that left the service, but now for the first time these same systems finding they cannot recruit and they can’t recruit because people are a lot more resistant to a negative work life balance. This is shifting so much that some healthcare researchers think in the next 10 years we are going to see a real difference in what the workforce actually looks like. It may be that improvement science will be very important in creating efficiencies when we no longer have people who don’t mind working 60 hours a week for too little pay. They going to work 30 or 40 hours and that’s it. We really need to understand what is gong on in these systems if we are going to help.

Different goals, different spheres of influence – Leaders and executives

As implementation researchers it is important to recognise that within every system there is going to be conflicting goals, conflicting outcomes, conflicting expectations, conflicting values. A big one, and one which you don’t hear about often is recognising what the executive leaders have to focus on. A lot of times they are focused on the political sphere, for sure the shareholder perspective (within the US more than other countries), the investor perspective even if they are non-profit, and the absolute need in their sphere to show growth, to show revenue, to show return on investment. In the NHS it is generally patient outcomes and the bottom line that matter most. There are also ever shifting political pressures.

In just the same way as the front-line experiences a lack of control over things, executives also have a limited sphere of influence and also experiences limited resources. There are leaders who are traumatised as a result. They are kind of at the edge of having to serve all of these external expectations while all the while being at some level motivated and engaged in wanting to serve patients and be the best that they can be. Not only do they have to deal with this ongoing tension, but they also have to contend with what is often their inability to make a significant difference due to limitations in the system and that is where their trauma and burnout can begin.

The front line

Then there is the front line where there are all these people who want to do the very best for their patients. For these people, not having to spend two hours auditing patient data after their kids go to bed would mean a lot. If too much work is being taken home within a setting this needs to be recognised. A goal then needs to be set to reduce that workload. That goal has on the surface nothing to do with how patients are being treated. It has nothing to do with the bottom line. Yet if that goal is integrated, it will probably end up being vital to the outcomes of the service. People are already stretched so thin; they don’t have absorptive capacity for change so we need to work collectively and figure out how we can we make these people’s work lives better. Service outcomes would improve because if the staff are less burnt out the patients would receive better care.

What can we do?

Implementation researchers will need to work with other disciplines to think how they can support people to do the best job they can, while aligning with the systems trying to achieve what is actually feasible. These systems really need something else from us.  The connection between burnout and moral injury (e.g. people in the care field not being able to do what they feel they are able to do because of constraints on the system and the work setting) is strong. But being able to work as a team together, all the time building trust and psychological safety, creating a receptive environment for failure as well as success, and making sure no question is a stupid question are all likely to be steps in the right direction. At the Improvement Academy I am often in meetings with a dozen people around a table who are not afraid to ask questions, raise concerns and share mistakes. Our directors Vishal and Michael as well as our ARC manager Sally also exhibit these behaviours which is very important for the team.

Despite the difficulties in the system, building a team like this at the micro level, within a connected sphere, even in an environment that is toxic or not great, can at least act as some sort of protection. There are ways that we as individuals, regardless of where we are placed within the organisation, have spheres of influence, we have spheres of control. We need to recognise what those spheres are and build those relationships with other people that can positively contribute to the work. Working in a team environment like this means people don’t feel like they are alone, people don’t feel like they have to shoulder the burden and it’s all up to them, or like they’re the only one who cares. Imagine going to work and you have a couple of people that are of like mind that you trust, but you can walk into their space close the door, go for a walk outside, have a conversation, these situations and people can be like a light in your work.

The reality is in most settings people are so maxed out that producing connected spheres like this is quite rare. Maybe the pendulum will start swinging the other way? Because it feels like systems have been ringing out as much energy and production from humans as possible within the health setting, e.g. seeing X number of health patients a day as a push. People have been pushed to their limits and it is time to focus on building those relationships. People must become more than the sum of the parts. People must not only work in silos and feel isolated. 

The fact is if we could ensure we worked to help teams in a way which was not just focused on efficiency, but which also ensured people who are engaged in improvement and implementation are empowered we would likely see a lot less burnout. We as human beings have an innate desire to make things better.  Whether it’s better in terms of efficiency or quality, we want to be engaged in making things better for ourselves, for our co-workers, for the people we serve. That’s an innate characteristic of none traumatised human beings. Just imagine if we had a system that promoted that? 

Our healthcare staff are speaking up with their feet and there is a reckoning that needs to occur. Leadership and middle management have a key role to play here but so do the rest of us whether researcher, patient or healthcare practitioner. We all have a tough task ahead of us and we will all need to work together if we are going to make things better. 

References

Albers, B., et al. (2020). “Implementation support practitioners – a proposal for consolidating a diverse evidence base.” BMC Health Services Research 20(1): 368.

Metz, A., et al. (2022a). “Is implementation research out of step with implementation practice? Pathways to effective implementation support over the last decade.” Implementation Research and Practice 3: 26334895221105585.

Metz, A., et al. (2022). “Building trusting relationships to support implementation: A proposed theoretical model.” Front Health Serv 2: 894599.

Nevedal, A., et al. (2023). Understanding sustainment challenges and opportunities from a longitudinal analysis of evidence-informed practices implemented in the veterans health administration. 16 th Annual Conference on the Science of Dissemination and Implementation, AcademyHealth.

Rapport, F., et al. (2022). “Too much theory and not enough practice? The challenge of implementation science application in healthcare practice.” J Eval Clin Pract 28(6): 991-1002.

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