What gets taken out of people when they’re in hospitals? And ways to put it back.
I’ve seen inside two hospitals recently -- I was in for 5 days in September (I had a kidney removed at Guy's Hospital) and 5 days this week (Bill, my 10 year-old, had his appendix removed at West Middlesex Hospital).
Got me thinking about hospitals and how we interact with other people there. This blog-post is about what else, apart from organs etc, gets removed from humans when they’re in hospital?
My training in ethnography and my interest in social-connectedness got me noticing how peculiarly people interact with one another in hospitals. Something seems to be missing from the relationships between patients and workers. And of course all this is particularly acute with Covid-19 -- adding to the workload of staff, and bringing with it the additional emotional role played by staff in situations where patient-visiting has been prohibited or limited.
And before anything else -- let me say how much I admire all the people who work in hospitals, and say how lucky I am to live in a rich-country with good healthcare. Thankyou.
This blog-post is about relationships and names. Tune in next week for one about exposure-to-differentness.
1 Relationships between staff and patients
The relationships between patients and staff are very weird in hospitals.
I suppose it starts with the fact that patients don’t want to be there in the first place; and when they’re in, they get “done to”: poked and tested and processed the whole time in ways they can’t anticipate or can’t understand or control. And of course they’re usually tired / drugged / stressed.
So given all that, you might hope for some normality and stability in the relational-modes in which workers interact with the patients, to help patients cope. But it’s the opposite - the ways in which workers and patients interact with one another is very strange, and leads to a harder experience for patients (and probably a less satisfying workplace for staff).
In trying to make sense of this weirdness, I noticed a few things:
Doctors always seek to give personalised care and to be kind, but most doctors have more confident expertise in my kidney or my appendix than in my personality or my emotional-needs. The physical work necessarily takes priority. At the level of each individual interaction, there’s always pressure and time-constraints, so it’s bound to be more effortful to view patients “in the whole” than as physical bodies.
Relationships don’t get thought about enough, because they are less important than the main job of saving lives etc. The risk of death haunts the whole place -- instilling deep fear in patients and conferring power on professionals.
Asymmetry of wanting to be there. Unlike other settings where people and workers interact routinely, like in a shop or on a bus or in a park, the non-worker doesn’t want to be there at all - they didn’t choose to be ill in hospital. Whereas all the staff are being paid (some handsomely and some insufficiently), and for the medical-staff, it’s often a thrilling place to be -- a dream-come-true, the culmination of decades of training and effort. .
Workers have similar cognitive constraints to patients (busy, stressed, often tired, hopefully not drugged) and act according to hard-wired customs and hierarchies and expectations and learned-behaviours.
Patients are often pathetically grateful to the high-status workers (the doctors and nurses). Pathetically as in: their suffering and their gratitude get compounded, and they become infantilised and quickly fall willingly into learned-helplessness.
When it comes to the support-staff (cleaners, caterers, porters), the interactions between the patients and them seem to be more like they are in other service-settings (eg in a canteen or a leisure-centre). Where they seem to become largely invisible to patients. What’s the expectation or training for the non-clinical staff when it comes to interacting with patients? Are they supposed to? Allowed to? Rewarded for it? Given training or scripts?
Perhaps the support-staff bear a disproportionate brunt of patients’ ill-temper and complaints. Because patients opt to present better versions of themselves to clinical staff (out of power-relations -- doctors can kill/cure me so I’ll please them) and offload their worst-selves to the support-staff?
2 It matters to focus on these interactions and relationships
I want to get deep into studying these relationships, and to figure out the best ways to restore and re-humanise these relationships, and to learn whether they matter (e.g. causal links to therapeutic-outcomes, shorter-stays, higher staff wellbeing and retention).
We at Neighbourly Lab have run experiments and co-design programmes with other areas in public-life (e.g. housing repairs, delivery-drivers) and we’re convinced that the relationships between “people who work in a place” and “people who live in a place” (or in the case of a hospital, visit a place) can be transformative for increasing social-connectedness. We are especially interested in the potential of relationships with support-staff and nursing-staff - because of the greater frequency and consistency of these relationships during the patient-stay.
3 One quick idea to test -- names and name-badges
But here’s a starter-for-ten suggestion. Names. Names are a wonder-drug for humanised relationships.
There’s a whole ethnography we want to do about names in hospitals.. Lots of quaint and lovely customs (lots of “sweetheart” and “darling”, lots of “this must be Dad.. hello Dad”, lots of “Thank you Doctor” where you wouldn't say “thank you Shopkeeper”)... And they matter especially during Covid-19, because distancing and masks give us fewer other ways to connect easily with one another.
So a treatment is: make name-badges mandatory for everyone in every hospital.
Names humanise us, they put us on a level. They give us a hand-hold, it’s a conversation-starter, and it gives people confidence in one another’s good intentions (I was just watching the scary scene in the Trial of the Chicago Seven where nasty cops remove their name-badges, presaging abusive violence).
Where there’s difference in ethnicity (very common in UK hospitals, where approx 80% of patients are white and 80% of staff are BAME), names can be difficult to recognise or remember, and that could compound feelings-of-difference or prejudice.
Names re-balance the strange power-relationships between patients and clinical-staff; and they elevate and humanise the support-workers (eg cleaners, porters) in the eyes of patients and colleagues. And knowing-names saves lives in hospitals (read Atul Gawande in Checklist Manifesto about how a routinisation of names-and-introductions in surgery helps junior staff to speak up if they see problems).
The wearing of name-badges feels like it would be acceptable to even the most traditional medic - it’s a baseline way to establish rapport and enable interaction, which is efficient, low-cost, risk-less and quick to trial.
Here’s a picture of Emma, a brilliant art-therapist at W Middlesex who was kind and professional, showing her name-badge. She had this one made herself because she and colleagues realised how important it is for establishing rapport and trust with patients.
And we could go one step farther than just names. Names plus a bit of personal info that offers a way to trigger “perspective-taking” empathy, or a conversational hand-hold. E.g. name badges that say “Sarah, I play tennis” or “Juan, I have baby twins” or “Malini, I’m into quiz-shows”.
Some hospitals do it more than others.. All the staff at Guys do the yellow “My name is ___ “ badges.
This initiative started 9 years ago by Kate Granger, a doctor who sadly became a patient and died, and observed “not showing names made me feel like I did not really matter, that these people weren’t bothered who I was. I ended up at times feeling like I was just a diseased body in a hospital bed.” West Middlesex don’t seem to do this -- I’m keen to find out why not.. Names on lanyards aren’t the answer here, as they’re too hard to see (50% twisted the wrong way, down at navel-height, often under an apron, often the legal ID name rather than the given-name.
And for patients too. They are named through bracelets and barcodes that allow efficient processing. Let’s have patients clearly named too, to ease interactions and build equivalence with staff and other patients. Names have power to surface up our shared humanity and make hospitals easier, nicer, kinder, better.