“Happy Organisations and Happy Workers” – blog post by Maria Quinlan

On the ARCH (Applied Research in Connected Health) website, research lead Dr Maria Quinlan  has a blog post entitled
“Happy Organisations and Happy Workers – a key factor in implementing digital health”

The whole is worth a read. Of course, having a happy organisation made up of happy workers is inherently important of itself, as well as from the point of view of implementing digital health. As Dr Quinlan writes in the first paragraph:

To paraphrase Tolstoy, “all happy organisations are alike; each unhappy organisation is unhappy in its own way.” The ability for healthcare organisations to innovate is a fundamental requirement for adopting and sustainably scaling digital health solutions.  If an organisation is unhappy, for example if it is failing to communicate openly and honestly, if staff feel overworked and that their opinion isn’t valued, it stands to reason that it will have trouble innovating and handling major complex transitions.

Reading this, I am struck by how important it is to make time in a day with an accumulation of pressing demands for reflection:


What these factors combine to achieve is happy, engaged workers – and happy workers are more effective, compassionate, and less likely to suffer burnout [2]. Clear objectives, praise, a sense that your voice matters – these can seem like fluffy ‘soft’ concepts and yet they are found over and over to be central to providing the right context within which new digital health innovations can flourish. Classic ‘high involvement’ management techniques – for example empowering team members to make decisions and not punishing them for every misstep are found to be key [1].  As Don Berwick of the Institute of Healthcare Improvement (IHI) says, people who feel joy in work are “not scared of data”, rather “joy is a resource for excellence” [3]

Managing what Sigal Barsade, Professor of Management at Wharton calls the ‘emotional’ culture of an organisation is a very important concept – especially in the healthcare environment which expects so much of staff [4]. Healthcare workers face pressures which many of us working in other fields can’t really comprehend, a recent systematic review found that clinicians have higher rates of suicidal ideation than the general population, with a high prevalence of burnout, psychiatric morbidity and depression linked to excessive workload [5].  Attempting to introduce innovative new ways of working within such constrained environments can be challenging to say the least. Exhausted workers, those with little time in their day for reflection, or those who work in organisations which fear failure are less likely to innovate [6].

Much of the rhetoric around healthcare innovation tends to be messianic in tone. A gap between this rhetoric and the messy, pressured reality of healthcare can diminish the credibility of innovators.

The concept of “adaptive reserve” is an important one, especially in the context of reforms and innovations being introduced into already pressured environments:

Drawing from their work researching healthcare organisations ability to handle complex transitions in the US, Jaen et al (2010) developed a 23-item scale measure for what they term ‘adaptive reserve’. Adaptive reserve is an internal capability for change which includes being agile; capable of continuous learning; and being adept at self-assessment, reflection and improvisation. The Adaptive Reserve questionnaire asks staff to rate their organisation according to a variety of statements which include statements such as; ‘we regularly take time to consider ways to improve how we do things’ and ‘this organisation is a place of joy and hope’.

Overall, this a fascinating blog post on an issue which is close to my heart. I intend to post some more on this topic over the next while.


” Further studies are needed in which patients are instructed to watch the fish.”

I previously noted a brief reference in a book on high rise life to the role of aquaria in fighting loneliness. There is a fair amount written about the calming effects of contemplating aquaria. This paper attempts to study the phenomenon empirically in a (very) particular patient group. It is also an example of an abstract selling a result in the way the paper doesn’t support… “trend towards significance” indeed!

Anthrozoös Vol. 16 , Iss. 3,2003


This study investigates the effect of an aquarium on pre-treatment anxiety, fear. frustration, and depression in electroconvulsive therapy (ECT) patients. Forty-two patients consecutively referred for ECT were rotated between rooms with and without aquariums. Self report measures of depression, anxiety, fear, and frustration were obtained, along with heart rate and blood pressure measurements. Preliminary mixed-model, repeated measures analysis of variance (ANOVA) revealed no significant differences between the aquarium and control conditions on any of the dependent measures. A trend toward significance was found for self reported anxiety (p=0.08) and further data were collected. Subsequent mixed model, repeated measures ANOVA confirmed the trend toward differences (p=0.08) in anxiety between the aquarium and control conditions. Factoring out demographic factors, the average patient experienced 12% less anxiety in the presence of an aquarium.

The authors describe how ECT is an effective, evidence-based psychiatric treatment, but that pre-treatment anxiety is an issue. Prior interventions have not been found significantly effective:

Educational interventions have been primarily developed to address this fear and anxiety; however, conflicting results have been reported regarding their effectiveness. One study focused on the effect of emotional support, provided by a psychiatric nurse in an educational context, on the anxiety levels of 32 ECT patients (Cohen 1970). The results revealed no significant difference in anxiety levels between patients receiving the intervention and those who did not. Another study involving 37 veteran psychiatric patients reported that while knowledge and behavioral intent showed positive changes following an educational ECT video, there was no reduction in fear (Battersby, Ben-Tovim and Eden 1993). Contrary results were reported using a continuous quality improvement model in which an educational video and written information were found to reduce anxiety. These findings are based on follow-up telephone interviews from15 patients (Harrison and Kaarsemaker 2000).

The authors describe animal-assisted therapy:

One environmental intervention, animal-assisted therapy (AAT), has been found to calm patients in some circum-; the benefits of interacting with companion animals are receiving increased attention in the healthcare industry. Studies have documented an association between pet ownership and reduced cardiovascular risk factors,improved one-year survival rates following myocardial infarction, reduction in minor health problems, and lower physician utilization (Friedmann et al.1980; Siegel 1990; Serpell 1991; Anderson, Reid and Jennings 1992). More recently, randomized controlled studies have shown a positive effect of pet ownership, or the presence of pets, on physiological indicators of reactivestress (Allen et al. 1991; Allen 2000; Allen, Shykoff and Izzo 2001; Allen,Blascovich and Mendes 2002). Interacting with companion animals has also been associated with reduced anxiety levels for non-psychiatric as well as inpatient psychiatric populations (Wilson 1991; Barker and Dawson1998). A significant reduction in anxiety was reported in a study involving 241 hospitalized psychiatric patients with a broad range of diagnoses fol-lowing 30 minutes of animal-assisted therapy (Barker and Dawson 1998).A more recent study found a significant reduction in fear following a 15-minute interaction with a therapy dog and its handler for 35 psychiatric patients waiting for electroconvulsive therapy (Barker, Pandurangi and Best 2003). No significant differences were found for anxiety or depression.

The authors describe the limitations of this study. One strikes me as fairly fundmental – patients were not asked to look at, or engage with the aquarium…. and in fact couldn’t, by and large, actually see it :

Similar to the results reported by Katcher, Segal and Beck (1984),blood pressure and heart rate readings were not significantly different for the patients in the aquarium and control conditions: the presence of an aquarium was not associated with reduced physiological measures of anxiety in patients waiting for ECT. However, unlike the earlier Katcher, Segaland Beck study, patients in this study were not asked to look at, or in anyway attend to, the aquarium, nor was it suggested to them that the aquarium would have a calming effect. Instead, the purpose of this study was to assess the impact of the mere presence of a fish aquarium. Further studies are needed in which patients are instructed to watch the fish.

The lack of significant findings in the present study may also be in part due to the background role of the aquarium. As patients were not seated in front of the aquarium or asked to look at it, they were not intentionally exposed to the potentially calming effect of watching the fish, unless they deliberately chose to do so. Most patients tended to lie down while in the holding rooms. In order to view the fish in this position, they would have to deliberately lie on one side. It may be necessary for patients to focus on the aquarium to derive benefit; a task that may be difficult for severely depressed patients. Also, the aquarium may not represent a powerful enough stimulus to distract patients from thoughts of their upcoming ECT treatment.

As neither study resulted in a significant reduction in anxiety, it maybe that the anxiety related to the ECT procedure is not amenable to the calming effects of animal-assisted activities. Also, the global nature of the visual analog scales used in both studies may not be sensitive to anxiety changes resulting from animal-assisted activities.

It does strike me that, as ECT is now reserved for specific indications and, by definition, those most severely ill, the anxiety and distress associated is likely to be at the more severe end of the spectrum – and less likely to respond to the passive presence of an aquarium.

Post for CCIO blog 20/02/17 – The “technodoctor” and putting stories at the heart of healthcare

Here is a post on the CCIO blog which I guess crystallises some of the thoughts I have posted here inspired by Cecil Helman. So this marks a culmination of sorts of engagement with his work.

The “technodoctor” and putting stories at the heart of healthcare

Cecil Helman was a South African-born GP who died in 2009 of motor neurone disease. He was also an anthropologist whose textbook, Culture, Health and Illness, remains a key reference and teaching text for medical anthropology. His approach to medicine, and life, is summed up in the words of one of his obituaries:

For Cecil literature and art were as important as the science of medicine. He was fascinated by people, their cultural and ethnic backgrounds, the narratives of their illnesses, their interaction with practitioners, and the role of traditional healers in many different societies. As he said, to be an effective healer, a doctor needs to ‘understand the storyteller as well as the story’.

Cecil_HelmanWhile his academic works have had a major influence on healthcare education and training, his most popular book was 2006’s Suburban Shaman a “mosaic of memories” of storytellers/patients and their stories, informed by his anthropological knowledge and approach. A posthumous sequel, An Amazing Murmur of the Heart, is a sort of sequel, in which Helman discusses the often-dehumanising process of medical education, during which the patient becomes something denatured, disconnected from their narrative. And in this book Helman identifies a new kind of doctor – the “technodoctor”:

Young Dr A, keen and intelligent, is an example of a new breed of doctor – the ones I call ‘techno-doctors’. He is an avid computer fan, as well as a physician. He likes nothing better than to sit in front of his computer screen, hour after hour, peering at it through his horn-rimmed spectacles, tap-tapping away at his keyboard. It’s a magic machine, for it contains within itself its own small, finite, rectangular world, a brightly coloured abstract landscape of signs and symbols. It seems to be a world that is much easier for Dr A to understand , and much easier for him to control, than the real world –  one largely without ambiguity and emotion.

Helman further identifies that this attitude marks a further step along the road of reductionism and dehumanising in medical care:

Like many other doctors of his generation – though fortunately still only a minority – Dr A prefers to see people and their diseases mainly as digital data, which can be stored, analysed, and then, if necessary, transmitted – whether by internet, telephone or radio – from one computer to another. He is one of those helping to create a new type of patient, and a new type of patient’s body – one much less human and tangible than those cared for by his medical predecessors. It is one stage further than reducing the body down to a damaged heart valve, an enlarged spleen or a diseased pair of lungs. For this ‘post-human’ body is one that exists mainly in an abstract, immaterial form. It is a body that has become pure information.

I was reminded by Robert Wachter’s speech at the 2016 CCIO Network Summer School in Leeds, on unintended consequences in health IT. He gave the example of hospitals where doctors are no longer to be found on the wards interacting with patients and other staff, but in a room full of doctors on computers, interacting with the EHR. The most stark illustration he used, however, was a child’s picture of a visit to the doctor, showing the doctor’s back turned to the child and her mother, tap-tapping away at the screen.

“A body that has become pure information” is how Helman describes the end process of the dehumanisation he decries. While I think the “technodoctor” is something of a straw man, Helman is certainly pointing to a genuine risk. “An Amazing Murmur of the Heart” is full of wisdom about the importance of connection, of physical touch, of attending to the story the patient brings, and the meaning of their symptoms for them. It would be a pity if this kind of rich, truly humanistic approach to medicine is somehow placed in opposition to the world of the “technodoctor.”

One way of avoiding the development of this false dichotomy into something tangible lies in Helman’s emphasis on the need to “understand the storyteller as well as the story.” What Helman doesn’t discuss in these passages is how paper-based information systems in healthcare can obscure the story and the storyteller in a welter of disjointed confusion. My own experience of paper notes is all too often wading through pages of confusing, if not illegible, notes, searching for something typewritten or printed. In this circumstance, the story the person is bringing to the encounter is utterly lost.

Initiatives like the EHR Personas allow for the conscientious, judicious use of narratives in planning and executing a major health IT change, one that could radically alter not only how healthcare is delivered but also how the personal story that is at the heart of all this activity is told.

Helman is, from the grave, issuing a warning, however, about what could go wrong. It is the same warning as that Bob Wachter gives with the child’s picture. It is fortunate that “narrative medicine” has become an academic subject in its own right, although perhaps this development indicates that something has been lost. In planning health IT interventions, we must ensure that they allow the story to be told and the storyteller to be heard. Let us focus on ensuring that the human stories that are the real stuff of every single clinical encounter are never lost, and that we turn our faces not to the screen but to those human stories.

“the distinction between myself as the individual people encounter, and the social role and character they expect to encounter”

I have been reflecting on this of late. It is a truism that “the Therapist” (in the sense Alasdair MacIntyre is using the term and also in the actual, clinical sense) is the locus for all sorts of projections – not just from clients/patients/”service users” but from other professions and society at large.

This is writ large in psychiatry, but is no doubt the case not only in the helping professions but across the board in life. We all encounter each other running the risk of mistaking the social role with the person.

Of course, this is somewhat inevitable in day to day life, especially in briefer encounters focused on a specific practical transaction. Indeed, entering absolutely into a deeply personal encounter with everyone you meet runs the risk of a certain paralysis.

However, I wonder how much organisational demoralisation is due to the dehumanising effect of this in encounter after encounter, especially in work – which is where a very high proportion of our working life is spent?