Be kind. Use systems. Improve care

Early in the COVID-19 pandemic, a doctor in Canada coined a phrase that came to embody the empathy needed to respond to a once-in-a-century event: Be Kind. Be Calm. Be Safe.1 Her message went on to emphasize the need for compassion, trust, information sharing, and avoiding stigma and blame.2 This leadership response was lauded for modeling humility, strength, collaboration, and empathy. In fact, empathy from health workers is an expectation of anyone seeking care, since worry, fear, and ambiguity are common experiences in health care. Nembhard et al., note in this issue, empathy among health workers is defined as “understanding and feeling a patient's emotions and perspective and offering a response (e.g., communication) that reflects understanding and aims to help” [emphasis added].3 This comprehensive review of the literature contributes to an understanding of empathy among all types of health workers—how it's measured, its relationship to care outcomes, and the interventions studied to improve empathy. The authors find that greater empathy among health workers is associated with better clinical performance, patient experiences, and health care outcomes. Importantly, greater empathy toward patients and co-workers is associated with improved clinician well-being, engagement, and decreased burnout. Nearly all the interventions aiming to increase empathy among health care workers were education programs such as communication skills-based trainings, workshops, simulations, or videos. Because educational interventions to increase empathy among individual health workers do not reliably increase empathy, the authors highlight the need for organizations to implement systems solutions in their conceptual model for empathy to improve care by increasing empathy among health care workers (HCWs). In this commentary, we consider (a) the need for interventions that are at the organizational level, (b) examples of how organizations can change systems to improve empathy among health care workers, and (c) the role of leadership in promoting empathy. Health care organizations increasingly recognize they have a vested interest, a responsibility even, to meaningfully improve worker well-being and engagement, which can contribute to increased empathy among HCWs.4, 5 Delivery systems have been spurred to act to improve the organizational climate and culture because of the impact of the COVID-19 pandemic on burnout, well-being, and retention, and the resulting ripple effects on the capacity of organizations to deliver high-quality patient care.6 The recommendations in the Nembhard et al review align with the evidence compiled in the National Academy of Sciences, Engineering, and Medicine (NASEM) report, “Taking Action Against Burnout: A Systems Approach to Professional Well-Being,” which has shifted the focus from improving well-being by targeting interventions at individual workers to focusing on how organizations can change systems.7 While the NASEM report focused specifically on well-being and burnout, the recommendations extend to cultivating empathy among HCWs, given empathy is intertwined with well-being. As emphasized by the NASEM report, when promoting empathy, health care organizations should be cautious about changes that target individual HCWs, such as trainings that focus on skills or mindfulness. Concerning then are Nembhard et al. findings that educational-based interventions are the most common type of intervention used to increase empathy among health care workers. It is unrealistic to expect individuals to demonstrate greater empathy given their already high levels of burnout.8 And, as Nembhard et al. note, there exist different expectations for expressing empathy that intersect with gender and other sociodemographic identities of HCWs. It is problematic that patients expect more empathy from HCWs who are minoritized9 (those who have been historically excluded or marginalized) in organizations and already have a higher burden of burnout.10 While Nembhard et al. identified few organizational-level interventions to increase empathy; there is a robust evidence base to inform actions from adjacent fields such as quality improvement in health care, well-being, and organizational change. Effective systems interventions to improve well-being and burnout—such as getting rid of “stupid stuff,” restructuring workflows and tasks, and empowering workers to improve workplaces—are certain acts of kindness to workers.7, 11, 12 When leaders actively listen to concerns and respond by empowering workers to improve their work environments, it is a demonstration of empathy—or kindness in action.13 Therefore, as we invest in improving worker well-being, we are nurturing empathy within organizations. Though organizations can likely improve HCW burnout and empathy in tandem, these actions alone may not be sufficient to create a culture of empathy. Organizations also need to integrate principles of kindness into existing and new workflows, processes, and systems so that empathy is infused through every level of the organization; when empathy is incorporated into systems, it becomes a routine expectation within an organization rather than an individual act of kindness.14 Small, yet consistent and intentional actions are beneficial in overcoming reliance on individuals' skills and goodwill and can ensure consistency. Cultural changes will happen because of the cumulative effect of these many, small actions.14-16 This has an important implication—embedding empathy within an organization does not have to include multiple committees, complex processes, or massive clinical transformation. Instead, it can be intentionally integrated into work on a day-to-day basis. Organizations can use a lens of empathy to consider how decisions and workflows demonstrate kindness and respect to both HCWs and patients. This consideration can be as simple as when making a decision always asking: Does this system, process, or action show empathy? Which group of HCWs are we leaning on or disadvantaging by this decision or process, and have we sought their input? The goal is to balance organizational needs with those of our teams and our patients while being attentive to equitable expectations. Organizations can promote empathy by structurally changing the work environment and by strategically leveraging environmental cues.17, 18 A tenet of a systems approach is that behaviors can also be changed by changing the environment. To promote empathy between patients and HCWs, for example, patient rooms can be designed to ensure seating and positioning of equipment to foster conversation between people. Similarly, as leaders and champions change their own behaviors to demonstrate empathy, it signals changes in behaviors and culture that are expected from others.19, 20 Leaders might, for example, explicitly communicate expectations of work-life boundaries by not sending emails or expecting responses outside of work hours. Promoting and respecting workplace boundaries is surely an expression of kindness. Organizations should consistently recognize and reward kindness by fostering a culture of genuine gratitude.14, 16, 21 And organizations could extend the “see something, say something” culture22 that is well established in quality improvement to also recognize kindness—promoting actions that advance kindness to ourselves (someone took the time they needed to stay healthy), kindness to our colleagues, and kindness to patients. Daily huddles could include a “listening” component where managers carve out time to actively hear their teams' thoughts, concerns, and ideas.20, 23 Recognizing that leadership exists at multiple levels of an organization, having managers and directors model empathic listening coupled with meaningful responses will, over time, contribute to creating a culture that supports empathy. Leaders have the vantage point, the ability to make decisions, and access to resources to shape organizations and set culture. Thus, ownership for cultivating empathy starts and ends with leadership. Leaders must consistently prioritize the well-being and needs of HCWs and patients. In every decision, communication, and workflow, leaders must ask: how are we considering and incorporating the needs of patients? Of HCWs? At a minimum, leaders must model kindness. No funding to report.

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