The importance of an ethical basis for medical practice has been emphasized in recent years. … Despite differences, these works often emphasize several common values orientations or ethical principles, including beneficence, nonmaleficence, justice, respect for patient autonomy, and confidentiality.
The importance of an ethical basis for medical practice has been emphasized in recent years. Several groups and countries have called for a broadly embraced, basic curriculum in ethics for students in the medical profession.1,2 The United States has no standardized curriculum in medical ethics, but ethics courses are now common in medical schools.1 Professional groups, hospitals, and certifying or accrediting boards such as the Joint Commission on the Accreditation of Health Care Organizations have emphasized the importance of ethical principles through their mission statements and procedures.
Various principles and values stated in numerous oaths and declarations form the basis for ethical practices in health care. The Hippocratic Oath is but one of these many oaths and declarations that have been recited by entering and newly graduated physicians over the centuries.3-6 Despite differences, these works often emphasize several common values orientations or ethical principles, including beneficence, nonmaleficence, justice, respect for patient autonomy, and confidentiality.3,4
Will this resurgence of interest in medical ethics be beneficial only to patients? This commentary reviews research suggesting that physicians and other health care professionals have an increased rate of burnout when they perceive that their ethical standards or values are not shared by the health care organizations with which they are affiliated. An emphasis on ethical practices, a values orientation in medicine, and the ability to negotiate differences may benefit not only patients but physicians and other health care professionals as well.
What Is Burnout? How Does It Relate to Values and Challenges to Professional Values?
Burnout is a well-recognized and empirically studied syndrome with 3 components: exhaustion, depersonalization (or detached, callous response to patients), and a sense of inefficacy in the workplace.7 Rates of burnout in medical fields are extremely high, reported by some studies to be around 50%.8 Maslach and Leiter9 identify 6 areas in the work environment that contribute to burnout: work overload, lack of control, insufficient reward, breakdown of community, absence of fairness, and conflicting values.
Although these areas can be considered conceptually distinct, threats or difficulties in one area may ultimately affect the individual’s overall values orientation and commitment to his or her work. According to the model of response to stress developed by Hobfoll,10,11 termed the conservation of resources theory, people attempt to maintain, develop, or enhance both their own internal sense of well-being and their external social situations (eg, their workplace) to increase the likelihood of receiving positive reinforcement. Resources are considered objects, personal characteristics, conditions, or energies that maintain or increase reinforcement. Basic beliefs, or the values people have, are examples of these resources, which “help to define for people who they are.”10
Physicians and other health care professionals, confronted with what they perceive to be overwhelming work demands or threats to their own values orientations, will respond to these threats or challenges in various ways, continually attempting to conserve their internal resources. However, overwhelming work demands or conflicts involving basic values make increased stress, diminished or depleted resources, and burnout more likely.
Incongruence of Values and Moral Strain: Definitions, Examples, and Importance in Burnout
Focusing more specifically on a values perspective, a loss or threat to values may occur when physicians or other health care professionals think that they are impeded from offering the type of clinical care they want to provide. Work overload and exhaustion are 2 such impediments and are well-recognized contributors to burnout.9,12
Incongruence of values, as studied by Leiter et al,13,14 and moral strain, as studied by Glasberg et al,15 are other means or pathways to burnout that are less well recognized. These occur when health care professionals sense a lack of alignment between their own values and those they perceive to be the values of various health care–related organizations or groups with which they are associated. This phenomenon is the primary focus of this commentary.
Physicians and other health care professionals are heavily involved with various medical organizations (eg, hospitals, health care clinics and agencies) and extraprofessional entities (eg, managed care organizations; governmental programs, such as Medicare and Medicaid) that strongly influence the extent and type of medical care that is provided. These entities often have mission and values statements that appear to convey their commitment to a values orientation and ethical practice in health care. Physicians and other health care professionals often question many of these commitments, however, as they come to feel frustrated and stressed by administrative, bureaucratic, or financial pressures that seem in many cases to be more oriented to these latter pursuits than to ethical or values-oriented care. Examples of situations that might make physicians and other health care professionals question the ethical and/or values orientation of their colleagues or the health care facility include the pressure to discharge patients too soon from the hospital, the pressure not to admit patients to the hospital because of cost or insurance status, the provision of a reduced level of care to patients without sufficient insurance coverage, the provision of minimal information about procedures, the avoidance of “less desirable” patients (eg, the sickest and most time-consuming), the failure to provide necessary information (or provision of it in a cursory and perfunctory manner), and the scheduling of insufficient time for patient visits.
Clearly, however, in some cases what is called unethical or callous by one group, such as health care professionals, may be seen from an entirely different perspective by colleagues or organizational leaders facing different pressures. Nonetheless, when the perception of a lack of professional values or unethical care occurs, internal conflicts develop in many health care professionals. Physicians and other health care professionals may find it difficult to reconcile their values with what they perceive to be false, misleading, or hypocritical values of the health care organization,13-15 a situation that illustrates the concept of incongruence of values. The actual values of the larger health care entity, from the physicians’ or health care professionals’ perspective, may have little to do with professional values such as beneficence, justice, or autonomy. In fact, practices that seem geared toward maximizing revenues and limiting resource availability, for example, may seem antithetical to the health care professionals’ values orientation and commitment.
Leiter14 studied a large group of nurses in acute care facilities who completed a series of questionnaires, including the Areas of Worklife Scale,16 which has several components that assess an individual’s impressions of his/her workplace. For example, questions on the values component of the Areas of Worklife Scale ask respondents to rate their level of agreement or disagreement with a given statement, such as “Working here forces me to compromise my values” or “My values and the organization’s values are alike.”
The findings showed that incongruence of values predicted all 3 burnout components of exhaustion, cynicism, and feelings of inefficacy. Workload imbalance was associated with the exhaustion component of burnout. As noted by Leiter,14 “For employees who are feeling the strain of challenging work, conviction that it is for a meaningful cause can be critical.”
In another study, Leiter13 surveyed members of physician-related organizations in Canada (eg, the Canadian Medical Association). Both excessive workload, the highly studied and well-accepted contributor to burnout, and incongruence of values were significant predictors of burnout. Both predicted the burnout components of exhaustion and cynicism (depersonalization), but only values incongruence also predicted a sense of professional inefficacy.
Glasberg et al15 have emphasized that health care is a moral undertaking. Health care professionals they have studied experience “[a] troubled conscience when they feel that they cannot provide the good care they wish—and believe is their duty—to give.” These investigators studied several hundred health care professionals, including physicians, using tools they had developed to assess empirically the effect of stress of conscience. The study was conducted in a Swedish health care district with a hospital and 8 primary health care centers. The Stress of Conscience Questionnaire, a 9-item scale that asks participants to rate whether and to what degree they have a “troubled conscience” when presented with a series of work situations, was used. Possible situations included “not living up to others’ expectations,” “lowering aspirations to provide good care,” “dealing with incompatible demands,” and “lacking the time to provide the care needed.” Participants in the study also completed the Maslach Burnout Inventory, the standard scale used to assess burnout. Significant associations were found between items on the Stress of Conscience Questionnaire, including “having to deaden one’s conscience” while working and “lacking the time to provide the care needed,” and burnout. Using regression analysis, these investigators found that stress of conscience issues were able to explain nearly 60% of the variance in the emotional exhaustion factor on the Maslach Burnout Inventory.15
Juthberg et al17 also studied stress of conscience and burnout in health professionals providing care for older people in Sweden. They again found a significant relationship between stress of conscience and burnout. Burnout was associated with “experiencing shortcomings in the health care environment,” “being exposed to contradictory demands,” and “having to deaden one’s conscience to continue working in that environment.”
Preventing/Addressing Burnout Due to Ethical or Values-Oriented Concerns
As already discussed, challenges to professional values and ethical principles such as beneficence are related to burnout in some physicians and other health care professionals. However, what is unethical or insufficiently attentive to a values orientation in health care for one individual or group may not be so for others.
Some professional practices are considered unethical by all or nearly all health care professionals. Such practices include deriving personal income by referring patients for particular tests or procedures in which the physician has a pecuniary interest, splitting fees and paying for referrals, or not providing full and necessary information about procedures. Examples of practices that would be considered unethical by some but not so by others are attending pharmaceutical industry–sponsored symposia or accepting nominal gifts from pharmaceutical industry representatives. Other practices would not be criticized on ethical grounds but might raise values-oriented objections. Not accepting low-paying patients with governmental insurance, such as Medicaid, might fall into this category for some.
When physicians or health care professionals witness their colleagues or their health care organization involved in these or similar situations, they may experience conflict or confusion about ethical principles or values, potentially leading to stress, demoralization, and burnout. The issue of perception is crucial, especially in the latter 2 instances of questionable ethical practices and/or a values orientation. For these types of situations, individual physicians and health care professionals as well as health care organizations as a whole would benefit from having regularly scheduled seminars, discussion groups, and consultations related to ethical practices and health care values. It is also important that leaders, both clinical and nonclinical (eg, executives, board members), have education and training related to ethical and values perspectives in health care.
Negotiation and conflict resolution skills are important and may be very helpful in many situations in which perspectives on ethics and values differ. These skills are considered desirable by health care leaders, but training in them is often lacking in medicine.18,19 Nonetheless, greater expertise in these areas should be fostered given that an individual’s perceptions of differences in values are a crucial determinant of burnout.
In some cases, appropriate confrontation by a concerned physician or health care professional of a health care organization perceived to be acting in an unethical manner or in a manner that lacks an adequate values orientation may help to alter these practices through professional discussion, negotiation, and conflict resolution skills. These efforts would improve not only the ethical commitment of the health care organization but also the health care professional’s morale and work engagement, a positive characteristic that is thought to be the opposite of burnout.9,20
The Table provides a series of approaches for physicians or health care professionals who consider their values to be “incongruent” with those of the health care organization with which they are associated. It may be asked whether these or other approaches actually will change a particular health care organization’s culture or behavior. This is not clear, but the findings in studies reported here and others suggest an additional approach toward engagement of health care entities that is an important step in the change process. As noted in the Table, addressing conflicts in ethical issues or values orientations should not rest only on the “rightness” of these issues but also on the costs of not addressing them. Studies of burnout suggest that incongruence of values probably has a financial cost to individuals, health care entities, and society in terms of patient care and the availability and competence of physicians and other health care professionals. Other studies have found that health care professionals, when faced with stress around ethical issues, are significantly more likely than their peers without these conflicts to consider leaving their current employment.21 Considerations such as these may increase the willingness of health care organizations to alter approaches, improve communication, or negotiate a variety of issues related to health care ethics and values.
Approaches for Physicians or Other Health Care Professionals Who Sense an Incongruence Between Their Values and Those of the Health Care Organizations With Which They Are Associated
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The title of this article asked who benefits from an ethical and values orientation in health care. Patients clearly do. Physicians, other health care professionals, and health care organizations also potentially benefit, but not only because of the satisfaction of conducting themselves in a professionally ethical manner. These groups will benefit by reducing burnout and its personal and professional consequences if attention to health care ethics and values reduces the realities or the perceptions of “incongruence” in these areas between health care professionals and the health care organizations with which they are associated.
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Articles from Mayo Clinic Proceedings are provided here courtesy of The Mayo Foundation for Medical Education and Research
Stewart Gabel, MD
Mayo Clin Proc. 2011 May; 86(5): 421–424.
doi: 10.4065/mcp.2010.0781CS AND VALUES IN CLINICAL PRACTICE