Confronting Health Worker Burnout and Well-Being

V. Murthy

NEJM, July 13, 2022

DOI: 10.1056/NEJMp2207252

Here is an excerpt:

Burnout manifests in individuals, but it’s fundamentally rooted in systems. And health worker burnout was a crisis long before Covid-19 arrived. Causes include inadequate support, escalating workloads and administrative burdens, chronic underinvestment in public health infrastructure, and moral injury from being unable to provide the care patients need. Burnout is not only about long hours. It’s about the fundamental disconnect between health workers and the mission to serve that motivates them.

These systemic shortfalls have pushed millions of health workers to the brink. Some 52% of nurses (according to the American Nurses Foundation) and 20% of doctors (Mayo Clinic Proceedings) say they are planning to leave their clinical practice. Shortages of more than 1 million nurses are projected by the end of the year (U.S. Bureau of Labor Statistics); a gap of 3 million low-wage health workers is anticipated over the next 3 years (Mercer). And we face a significant shortage of public health workers precisely when we need to strengthen our defenses against future public health threats. Health worker burnout is a serious threat to the nation’s health and economic security.

The time for incremental change has passed. We need bold, fundamental change that gets at the roots of the burnout crisis. We need to take care of our health workers and the rising generation of trainees.

On May 23, 2022, I issued a Surgeon General’s Advisory on health worker burnout and well-being, declaring this crisis a national priority and calling the nation to action with specific directives for health systems, insurers, government, training institutions, and other stakeholders. The advisory is also intended to broaden awareness of the threat that health worker burnout poses to the nation’s health. Public awareness and support will be essential to ensuring sustained action.

Addressing health worker well-being requires first valuing and protecting health workers. That means ensuring that they receive a living wage, access to health insurance, and adequate sick leave. It also means health workers should never again go without adequate personal protective equipment (PPE) as they have during the pandemic. Current Biden administration efforts to enhance domestic manufacturing of PPE and maintain adequate supplies in the Strategic National Stockpile will continue to be essential. Furthermore, we need strict workplace policies to protect staff from violence: according to National Nurses United, 8 in 10 health workers report having been subjected to physical or verbal abuse during the pandemic.

Second, we must reduce administrative burdens that stand between health workers and their patients and communities. One study found that in addition to spending 1 to 2 hours each night doing administrative work, outpatient physicians spend nearly 2 hours on the electronic health record and desk work during the day for every 1 hour spent with patients — a trend widely lamented by clinicians and patients alike. The goal set by the 25×5 initiative of reducing clinicians’ documentation burden by 75% by 2025 is a key target. To help reach this goal, health insurers should reduce requirements for prior authorizations, streamline paperwork requirements, and develop simplified, common billing forms. Our electronic health record systems need human-centered design approaches that optimize usability, workflow, and communication across systems. Health systems should regularly review internal processes to reduce duplicative, inefficient work. One such effort, Hawaii Pacific Health’s “Getting Rid of Stupid Stuff” program, has saved 1700 nursing hours per month across the health system.

The info is here.

Advance directives for mental illness raise deep ethical questions

Tania Gergel

psyche.co

Originally posted 3 AUG 2022

Here is an excerpt:

What about the potential drawbacks? 

Medical ethicists worry that self-binding directives might allow involuntary treatment to be imposed on someone at an early stage of illness, while they are still capable of making an informed decision about treatment. How can we be sure that someone lacks what is known, in medical law, as ‘decision-making capacity’ and that we should be turning to the instructions in a document rather than what they are saying right now? Human rights advocates, such as the United Nations Committee on the Rights of Persons with Disabilities, go so far as to state that all involuntary treatment is a violation of an individual’s fundamental human rights.

The debate over self-binding directives has been working through these issues since the 1980s. However, one voice that was largely missing was the voice of ‘lived experience’. The arguments have gone backwards and forwards without asking the opinions of those who have the most intimate knowledge of what it is like to be unwell, and the likely consequences of illness; the very people who have found themselves hospitalised for mental illness and who may well have received involuntary treatment.

As part of ongoing research into mental health advance directives, our team at King’s College London conducted an internet survey in partnership with the charity Bipolar UK. We asked people who have lived with bipolar lots of questions about their views and any experiences of any forms of advance decision-making in relation to their condition. One of the questions we asked participants was whether they thought self-binding directives were a good idea and why they thought this. We found that 82 per cent of participants endorsed the self-binding directive idea, with the vast majority explaining this endorsement in terms of experiencing a determinate shift to distorted thinking and decision-making when they are unwell.

While ethicists might feel that the risk that someone retains decision-making capacity is a barrier to self-binding directives, many participants were adamant that their decision-making is impaired when they are unwell, and often mentioned ‘capacity’ in their responses, even though it was not alluded to within the questions themselves. A good example was this response:

You are unwell and lack capacity. I [recognise this now] looking back at when I was last sectioned, but my views were very different at the time due to my illness. It is my well views and opinions that should be acted upon.

Some people described this transition in terms of a shift of ‘self’, suggesting that illness makes them an entirely different person from their well self. As a philosopher working on medical ethics and law, I am particularly interested in questions about personal identity and illness, so it was fascinating to see answers such as this:

When psychotic or manic or depressed you can become another person and irrational. It is easy to make bad decisions when ill that may not be in my best interest.

When participants referred to the practical consequences and risks of illness, they were often related to suicide. People talked about how their ill self impelled them towards death in a way that was utterly inconsistent with their wishes when well.

The info is here.

Reducing Explicit Blatant Dehumanization by Correcting Exaggerated Meta-Perceptions

Landry, A. P., Schooler, J. W., Willer, R., 

& Seli, P. (2022). 

Social Psychological and Personality Science.

https://doi.org/10.1177/19485506221099146

Abstract

If explicitly, blatantly dehumanizing a group of people—overtly characterizing them as less than human—facilitates harming them, then reversing this process is paramount. Addressing dehumanization among American political partisans appears especially crucial, given that it has been linked to their anti-democratic hostility. Perhaps because of its overt nature, partisans recognize—and greatly exaggerate—the extent to which out-partisans explicitly, blatantly dehumanize them. Past research has found that when people perceive they are dehumanized by an outgroup (i.e., meta-dehumanization), they respond with reciprocal dehumanization. Therefore, we reasoned that partisans’ dehumanization could be reduced by correcting their exaggerated meta-dehumanization. Indeed, across three preregistered studies (N = 4,154), an intervention correcting American partisans’ exaggerated meta-dehumanization reduced their own dehumanization of out-partisans. This decreased dehumanization persisted at a 1-week follow-up and predicted downstream reductions in partisans’ anti-democratic hostility, suggesting that correcting exaggerated meta-dehumanization can durably mitigate the dark specter of dehumanization.

Discussion

Explicit blatant dehumanization continues to mar contemporary intergroup relations (Kteily & Landry, 2022). For instance, a troubling number of American partisans explicitly, blatantly dehumanize one another, which has been linked to their anti-democratic hostility (e.g., Moore-Berg et al., 2020). We sought to reduce partisan dehumanization by integrating research demonstrating that (a) individuals who think an outgroup dehumanizes their own group (i.e., meta-dehumanization) respond with reciprocal dehumanization (Kteily et al., 2016; Landry, Ihm & Schooler, 2022) and (b) individuals attribute overly-negative attitudes to outgroup members (Lees & Cikara, 2021). We developed an intervention informing American partisans of their tendency to overestimate how much they are dehumanized by out-partisans (Landry, Ihm, Kwit & Schooler, 2021; Moore-Berg et al., 2020). This reduced partisans’ own dehumanization of out-partisans across three studies–an effect that persisted at a 1-week follow-up.

Correcting partisans’ meta-dehumanization also produced modest—yet reliable—reductions in their anti-democratic hostility. This is notable given recent work finding that interventions reducing negative affect do not influence anti-democratic attitudes (Broockman et al., 2020; Voelkel et al., 2021). Perhaps our dehumanization-focused intervention reduced anti-democratic attitudes when affect-focused interventions did not because dehumanization is more strongly linked to anti-democratic attitudes. Indeed, we observed particularly strong indirect effects of the intervention on reduced anti-democratic spite through dehumanization (average βindirect = −.23, compared to an average βindirect = −.03 for negative affect; see also Landry, Ihm & Schooler, 2022). Although experimental tests of mediation are needed to confirm this cross-sectional indirect effect, future work attempting to bolster support for democratic norms should consider the promise of targeting dehumanization.

‘The entire protein universe’: AI predicts shape of nearly every known protein

Ewen Callaway

Nature (608)

Posted with correction 29 July 22

From today, determining the 3D shape of almost any protein known to science will be as simple as typing in a Google search.

Researchers have used AlphaFold — the revolutionary artificial-intelligence (AI) network — to predict the structures of more than 200 million proteins from some 1 million species, covering almost every known protein on the planet.

The data dump is freely available on a database set up by DeepMind, the London-based AI company, owned by Google, that developed AlphaFold, and the European Molecular Biology Laboratory’s European Bioinformatics Institute (EMBL–EBI), an intergovernmental organization near Cambridge, UK.

“Essentially you can think of it covering the entire protein universe,” DeepMind chief executive Demis Hassabis said at a press briefing. “We’re at the beginning of a new era of digital biology.”

The 3D shape, or structure, of a protein is what determines its function in cells. Most drugs are designed using structural information, and the creation of accurate maps of proteins’ amino-acid arrangement is often the first step to making discoveries about how proteins work.

DeepMind developed the AlphaFold network using an AI technique called deep learning, and the AlphaFold database was launched a year ago with more than 350,000 structure predictions covering nearly every protein made by humans, mice and 19 other widely studied organisms. The catalogue has since swelled to around 1 million entries.

“We’re bracing ourselves for the release of this huge trove,” says Christine Orengo, a computational biologist at University College London, who has used the AlphaFold database to identify new families of proteins. “Having all the data predicted for us is just fantastic.”

(cut)

But such entries tend to be skewed toward human, mouse and other mammalian proteins, Porta says. It’s likely that the AlphaFold dump will add significant knowledge, because it includes such a diverse range of organisms. “It’s going to be an awesome resource. And I’m probably going to download it as soon as it comes out,” says Porta.

The info is here.

Disintegrating and Reintegrating the Self – (In)Flexible Self-Models in Depersonalisation and Psychedelic Experiences

Ciaunica, A., & Safron, A. (2022, March 13).

https://doi.org/10.31234/osf.io/mah78

Abstract

Across times and cultures, humans constantly and intentionally tried to ‘lose’ or to ‘escape’ their familiar, ordinary self, to ‘self-detach’ and to radically change the ways of perceiving oneself and the world. In this paper we explore the contrast between the feeling of ‘losing’ the sense of familiarity with one’s self and body in Depersonalisation experiences (DP) and psychedelics (with some consideration of meditative experiences). We explore these radical changes in self-experiences through the lens of Active Inference Framework (AIF). AIF is a process theory aiming to capture the capacity of biological organisms (e.g. living human bodies) to survive and thrive in volatile and uncertain environments. In line with previous work on depersonalisation and psychedelic mechanisms, we suggest that such experiences can involve a stance with radically altered prior expectations, so providing opportunities for flexibly modulating self- and world models. Specifically, we suggest that controlled acquisition of new self- and world models may enhance the plasticity of one’s perceptual and sensorimotor experiences. This new gained flexibility, we claim, may allow the individual to ‘leave behind’ certain habits, perceptual rigidities that holds him/her ‘stuck’ in certain behavioural patterns. And to open to new ways of perceiving and integrating self- and world-related information. By contrast, depersonalisation experiences point to a uncontrolled phenomenon of non-flexible (rigid) (dis)integration of ordinary/habitual self-models, and a consequent feeling of being ‘stuck’ in one’s mind. While controlled (dis)integration of habitual self-experiences and consequent re-integration may have positive effect, uncontrolled (dis)integration of habitual self-experiences triggered by unpredictable life events may be overwhelming and lead to self-detachment and potentially adverse clinical outcomes. Contrasting these two modes of alteration will allow us to outline the importance of the controlled ability to flexibly integrate, disintegrate and reintegrate multisensory bodily signals, and its impact on the human sense of self and agency.

Conclusion

In these explorations we have considered the experience of ‘losing’ one’s familiar sense of self in Depersonalisation (DP) and psychedelic experiences through the (perhaps often overly opaque) lens of Active Inference. Depersonalisation is characterized by feelings of being detached from one’s self, body, and world.We suggested that acquisition of new self-and world models may enhance the plasticity of one’s perceptual and sensorimotor experiences. This new gained flexibility, we posited, may allow the individual to ‘leave behind’ certain habits, perceptual rigidities that holds him/her ‘stuck’ in certain behavioural patterns, and open to new ways of perceiving and integrating self-and world-related information. This adaptive modelling may be achieved during psychedelic (and potentially meditative) experiences via a flexibly controllable(dis)integration of ordinary/habitual self-models, and a consequent re-integration or re-organisation of the latter via modulatory multisensory information.

By contrast, depersonalisation experiences point to a phenomenon of non-flexible (rigid) (dis)integration of ordinary/habitual self-models, and a consequent feeling of being ‘stuck’ in one’s mind. While controlled (dis)integration of habitual self-experiences and consequent re-integration may have positive effects, uncontrolled (dis)integration of habitual self-experiences triggered by unpredictable life events may be overwhelming and lead to self-detachment and potentially adverse clinical outcomes such as depersonalisation disorder. 

The info is here.

When does moral engagement risk triggering a hypocrite penalty?

Jordan, J. & Sommers, R.

Current Opinion in Psychology

Volume 47, October 2022, 101404

Abstract

Society suffers when people stay silent on moral issues. Yet people who engage morally may appear hypocritical if they behave imperfectly themselves. Research reveals that hypocrites can—but do not always—trigger a “hypocrisy penalty,” whereby they are evaluated as more immoral than ordinary (non-hypocritical) wrongdoers. This pattern reflects that moral engagement can confer reputational benefits, but can also carry reputational costs when paired with inconsistent moral conduct. We discuss mechanisms underlying these costs and benefits, illuminating when hypocrisy is (and is not) evaluated negatively. Our review highlights the role that dishonesty and other factors play in engendering disdain for hypocrites, and offers suggestions for how, in a world where nobody is perfect, people can engage morally without generating backlash.

Conclusion: how to walk the moral tightrope

To summarize, hypocrites can—but do not always—incur a “hypocrisy penalty,” whereby they are evaluated more negatively than they would have been absent engaging. As this review has suggested, when observers scrutinize hypocritical moral engagement, they seem to ask at least three questions. First, does the actor signal to others, through his engagement, that he behaves more morally than he actually does? Second, does the actor, by virtue of his engagement, see himself as more moral than he really is? And third, is the actor's engagement preventing others from reaping benefits that he has already enjoyed? Evidence suggests that hypocritical moral engagement is more likely to carry reputational costs when the answer to these questions is “yes.” At the same time, observers do not seem to reliably impose a hypocrisy penalty just because the transgressions of hypocrites constitute personal moral failings—even as these failings convey weakness of will, highlight inconsistency with the actor's personal values, and reveal that the actor has knowingly done something that she believes to be wrong.

In a world where nobody is perfect, then, how can one engage morally while limiting the risk of subsequently being judged negatively as a hypocrite? We suggest that the answer comes down to two key factors: maximizing the reputational benefits that flow directly from one's moral engagement, and minimizing the reputational costs that flow from the combination of one's engagement and imperfect track record. While more research is needed, here we draw on the mechanisms we have reviewed to highlight four suggestions for those seeking to walk the moral tightrope.

The info is here.

Narrative Capacity

Toomey, James, (August 31, 2021).

100 N.C. L. Rev. 1073

Available at SSRN: https://ssrn.com/abstract=3914839

Abstract

The doctrine of capacity is a fundamental threshold to the protections of private law. The law only recognizes private decision-making—from exercising the right to transfer or bequeath property and entering into a contract to getting married or divorced—made with the level of cognitive functioning that the capacity doctrine demands. When the doctrine goes wrong, it denies individuals, particularly older adults, access to basic private-law rights on the one hand and ratifies decision-making that may tear apart families and tarnish legacies on the other.

The capacity doctrine in private law is built on a fundamental philosophical mismatch. It is grounded in a cognitive theory of personhood, and determines whether to recognize private decisions based on the cognitive abilities thought by philosophers to entitle persons in general to unique moral status. But to align with the purposes of the substantive doctrines of property and contract, private-law capacity should instead be grounded in a narrative theory of personal identity. Rather than asking whether a decision-maker is a person by measuring their cognitive abilities, the doctrine should ask whether they are the same person by looking to the story of their life.

This Article argues for a new doctrine of capacity under which the law would recognize personal decision-making if and only if it is linked by a coherent narrative structure to the story of the decision-maker’s life. Moreover, the Article offers a test for determining which decisions meet this criterion and explains how the doctrine would work in practice.

Conclusion

Scholars and courts have long recognized that the threshold doctrine of capacity in private law requires reform to meet the needs of our aging society.  What they have not clearly seen is the doctrine’s fundamental error—a philosophical misalignment between the legal test, based on the construct of personhood, and its purposes, which are concerned with personal identity. This Article has excavated this distinction. And it has articulated and evaluated an alternative.

We think of ourselves as stories and we make meaning of our lives through our stories. That is what is at stake in the doctrine of capacity—whether an individual may continue to write their story by making decisions and choices.  Concern for the stories of our lives should be a paramount guiding principle of the capacity doctrine. In short, courts should only intervene in our decision-making where the story we would tell with our choices ceases to be our story at all.

A pdf is here.

Free Ethics CE

I will support Beth Rom-Rymer's voting kickoff for APA President-Elect with a continuing education program!!

I will be presenting a free CE on September 15, 2022 on the first day of voting for APA President-Elect.  I will be encouraging participants to vote in the APA election, and put Beth in the #1 space.

This will be the first in a series of three free workshops to promote Beth's candidacy.

Here is the link to the CE event to register.

Here is the long link.

https://events.eventzilla.net/e/integrating-moral-values-with-ethical-decisionmaking-2138578426

Here is a link for Dr. Rom-Rymer's campaign web site.

Violence against women at work

Adams-Prassl, A., Huttunen, K., Nix, E., 

& Zhang, N. (2022). University of Oxford.

Working Paper

Abstract

Between-colleague conflicts are common. We link every police report in Finland to administrative data to identify assaults between colleagues, and economic outcomes for victims, perpetrators, and firms. We document large, persistent labor market impacts of between colleague violence on victims and perpetrators. Male perpetrators experience substantially weaker consequences after attacking women compared to men. Perpetrators’ economic power in male-female violence partly explains this asymmetry. Male-female violence causes a decline in women at the firm. There is no change in within-network hiring, ruling out supplyside explanations via "whisper networks". Only male-managed firms lose women. Female managers do one important thing differently: fire perpetrators.

Discussion

Our results have a number of implications. First, female victims of workplace violence have few economic incentives to report violence at work. Even in the relatively severe cases reported to the police in our data, the male perpetrator experiences relatively small labor market costs for his actions. This is consistent with the vast under-reporting of workplace harassment and abuse suggested by survey data. A major, known problem in preventing harassment at work is that victims rarely report the problem to their employer (Magley, 2002). Women under-reporting harassment and violence at the hands of a colleague (and in particular one’s manager) is easily reconciled with the comparative lack of career consequences for perpetrators of male-female violence we have documented.

Second, given that under-reporting is common, we are likely only observing a small fraction of all cases of workplace violence. As described in Section 2, just 10% of physical assaults are reported to the police in Finland, with lower reporting rates for crimes considered less serious by the victim (EU Agency for Fundamental Rights, 2015; European Institute for Crime Prevention & Control, 2009). Conservatively, this implies that the incidence of workplace violence is at least 10 times larger than can be documented by police reports. At the same time, under-reporting and selective reporting is relevant for the external validity of our results. While we provide the first evidence of the causal impacts of workplace violence on perpetrators, victims, and the broader firm we can only do so for the (likely) more severe cases reported to police. We might not expect to see quite as large of impacts on victims, perpetrators, and the firm from less severe abuse by colleagues.

A pdf is here.