What’s Love Got to Do with It? A Longitudinal Study of the Culture of Companionate Love and Employee and Client Outcomes in a Long-term Care Setting, Barsdale and O’Neill 2014

I have blogged before about the relationship between morale and clinical outcomes. From 2014 in Administrative Science Quarterly , a paper which links this with another interest of mine, workplace friendships .

Here is the abstract:

In this longitudinal study, we build a theory of a culture of companionate love—feelings of affection, compassion, caring, and tenderness for others—at work, examining the culture’s influence on outcomes for employees and the clients they serve in a long-term care setting. Using measures derived from outside observers, employees, family members, and cultural artifacts, we find that an emotional culture of companionate love at work positively relates to employees’ satisfaction and teamwork and negatively relates to their absenteeism and emotional exhaustion. Employees’ trait positive affectivity (trait PA)—one’s tendency to have a pleasant emotional engagement with one’s environment—moderates the influence of the culture of companionate love, amplifying its positive influence for employees higher in trait PA. We also find a positive association between a culture of companionate love and clients’ outcomes, specifically, better patient mood, quality of life, satisfaction, and fewer trips to the emergency room. The study finds some association between a culture of love and families’ satisfaction with the long-term care facility. We discuss the implications of a culture of companionate love for both cognitive and emotional theories of organizational culture. We also consider the relevance of a culture of companionate love in other industries and explore its managerial implications for the healthcare industry and beyond.

Few outcomes are as “hard” – or as appealing to a certain strand of management – than “fewer trips to the emergency room.” The authors squarely and unashamedly go beyond the often euphemistic language of this kind of paper to focus on love:

‘‘Love’’ is a word rarely found in the modern management literature, yet for more than half a century, psychologists have studied companionate love— defined as feelings of affection, compassion, caring, and tenderness for others—as a basic emotion fundamental to the human experience (Walster and Walster, 1978; Reis and Aron, 2008). Companionate love is a far less intense emotion than romantic love (Hatfield and Rapson, 1993, 2000); instead of being based on passion, it is based on warmth, connection (Fehr, 1988; Sternberg, 1988), and the ‘‘affection we feel for those with whom our lives are deeply intertwined’’ (Berscheid and Walster, 1978: 177). Unlike self-focused positive emotions (such as pride or joy), which center on independence and self- orientation, companionate love is an other-focused emotion, promoting interdependence and sensitivity toward other people (Markus and Kitayama, 1991; Gonzaga et al., 2001).

Companionate love is therefore distinct from the romantic love which so dominates our thought when we think about love. As is often the case, we moderns are not nearly as new in our thinking as we would like to see ourselves:

Considering the large proportion of our lives we spend with others at work (U.S. Bureau of Labor Statistics, 2011), the influence of companionate love in other varied life domains (Shaver et al., 1987), and the growing field of positive organizational scholarship, which focuses on human connections at work (Rynes et al., 2012), it is reasonable to expect that this basic human emotion will not only exist at work but that it will also influence workplace outcomes. Although the term ‘‘companionate love’’ had not yet been coined, the work of early twentieth-century organizational scholars revealed rich evidence of deep connections between workers involving the feelings of affection, caring, and compassion that comprise companionate love. Hersey’s (1932) daily experi- ence sampling study of Pennsylvania Railroad System employees, for example, recorded the importance of caring, affection, compassion, and tenderness, as well as highlighting the negative effects when these emotions were absent, particularly in relationships with foremen. Similarly, Roethlisberger and Dickson’s (1939) detailed study of factory life provided crisp observations of companionate love in descriptions of workers’ interactions, describing supervisors who showed genuine affection, care, compassion, and tenderness toward their employees.

There is nothing new under the sun. In subsequent decades this kind of research was abandoned.  The authors go on to describe the distinctions between strong and weak cultures of companionate love:

Like the concept of cognitive organizational culture, a culture of companio- nate love can be characterized as strong or weak. To picture a strong culture of companionate love, first imagine a pair of coworkers collaborating side by side, each day expressing caring and affection toward one another, safeguarding each other’s feelings, showing tenderness and compassion when things don’t go well, and supporting each other in work and non-work matters. Then expand this image to an entire network of dyadic and group interactions so that this type of caring, affection, tenderness, and compassion occurs frequently within most of the dyads and groups throughout the entire social unit: a clear picture emerges of a culture of companionate love. Such a culture involves high ‘‘crystallization,’’ that is, pervasiveness or consensus among employees in enacting the culture (Jackson, 1966).

An example of high crystallization appears in a qualitative study of social workers (Kahn, 1993) in which compassion spreads through the network of employees in a ‘‘flow and reverse flow’’ of the emotion from employees to one another and to supervisors and back. This crystallization of companionate love can cross organizational levels; for example, an employee at a medical center described the pervasiveness of companionate love through- out the unit: ‘‘We are a family. When you walk in the door, you can feel it. Everyone cares for each other regardless of whatever level you are in. We all watch out for each other’’ (http://auroramed.dotcms.org/careers/employee_ voices.htm). Words like ‘‘all’’ and ‘‘everyone’’ in conjunction with affection, caring, and compassion are hallmarks of a high crystallization culture of companio- nate love.

Another characteristic of a strong culture of companionate love is a high degree of displayed intensity (Jackson, 1966) of emotional expression of affec- tion, caring, compassion, and tenderness. This can be seen in the example of an employee diagnosed with multiple sclerosis who described a work group whose members treated her with tremendous companionate love during her daily struggles with the condition. ‘‘My coworkers showed me more love and compassion than I would ever have imagined. Do I wish that I didn’t have MS? Of course. But would I give up the opportunity to witness and receive so much love? No way’’ (Lilius et al., 2003: 23).

In weak cultures of companionate love, expressions of affection, caring, compassion, or tenderness among employees are minimal or non-existent, showing both low intensity and low crystallization. Employees in cultures low in companionate love show indifference or even callousness toward each other, do not offer or expect the emotions that companionate love comprises when things are going well, and do not allow room to deal with distress in the workplace when things are not going well. In a recent hospital case study, when a nurse with 30 years of tenure told her supervisor that her mother-in- law had died, her supervisor responded not with compassion or even sympathy, but by saying, ‘‘I have staff that handles this. I don’t want to deal with it’’ (Lilius et al., 2008: 209). Contrast this reaction with one from the billing unit of a health services organization in which an employee described her coworkers’ reactions following the death of her mother: ‘‘I did not expect any of the compassion and sympathy and the love, the actual love that I got from co-workers’’ (Lilius et al., 2011: 880).

This is obviously a paper I could simply post extracts from all day but at this point I will desist. Perhaps rather than “What’s Love Got to Do With It? the authors could have invoked “All You Need is Love?”

Piece on cardiac surgery in Times Literary Supplement

In the current TLS I have a review of two books on cardiac surgery. One is Stephen Westaby’s  memoir of his career, the other is Thomas Morris’ historical perspective.

The full text is not freely available online, so here is the bit the TLS have made available to tease you all:

It is tempting to place Stephen Westaby’s Fragile Lives, a memoir of his career as a heart surgeon, in the category the journalist Rosamund Urwin recently called “scalpel lit”; following Atul Gawande’s Complications (2002) and Henry Marsh’s Do No Harm (2014) and Admissions (2017), here is another dispatch from a world arcane even for the majority of doctors. To some degree, Westaby’s book follows the Marsh template. In cardiac surgery as in neurosurgery, life and death are finely poised, and even minor technical mishaps by the surgeon, or brief delays in getting equipment to theatre, can have catastrophic consequences.

Like Marsh, Westaby, a consultant at the John Radcliffe hospital in Oxford, is jaundiced about the bureaucracy of health care and the mandatory “training” imposed on even the most experienced practitioners – “writing my personal development plan at the age of sixty-eight”. Now that death rates are published by the NHS,…

Makes you want to read the whole thing, does it not?

As it happens, Henry Marsh’s Admissions is reviewed in the same issue by George Berridge.

Leandro Herrero – What I learnt from the monks: a little anthropology of leadership and space in one page.

Another Daily Thought from Leandro Herrero that I am tempted to simply cut and paste completely. The whole thing is worth reading. I have blogged on my other site a fair about both the positive side of monastic practice and the risk of romanticising monasticism with the attendant danger of spiritual pride.

Monasteries were, of course, key institutions in the development of Western institutional life and culture. We often like to think that we have moved way way beyond learning from the communal life of monasteries. Of course, the themes and patterns of human interaction recur in superficially different guises:

There is something special about creating space. For me, leadership is mainly architecture: create the conditions, find the spaces, protect them, make them liveable. Architects also have maps, and compasses. The leader needs to provide maps (frameworks, such as the non negotiable behaviours) and navigation tools (a value system). But, above all, it’s about space.

Providing spaces for people to breath, to growth, to deliver something, to get better, to think critically, to interact, to collaborate, to travel together. This is all about space. Space is the psychological sister of place. Space may be only, or mainly, mental. As such, it is a precious asset. No wonder the word space has been often associated to the word sacred. As in sacred spaces. To provide space, to create and protect spaces for others, is something a good leader does. It’s a great deal of his servant-ship.

But we, sometimes, are not very good at this. We take over other people’s spaces by insisting in discussing, wanting to ‘go deeper’, being intolerant with leaving things open, dictating our own terms and providing unreasonable borders to their spaces.

At a threshold point of two people living together in one place, they may come to inhabit one single space. It requires a lot of maturity to live in one single space with others. Occupying one single place, is the easier part, space is not. Indeed, that single space may end up being too much to ask. It may be better to have separate spaces to respect, often overlap. Psychotherapists have known for many years that a temporary split, or making tangential connections for a while, may be the solution to some problems. Un-bundle the spaces that have become blurred, that is.

#OceanOptimism, powerlessness, hope, and change.

The current BBC Wildlife Magazine has a fascinating article by Elin Kelsey, of the Ocean Optimism Project, on how media-fuelled environmental despair and nihilism ends up demoralising people to the degree that positive action seems impossible. She cites much research on the “finite pool of worry” and the paralysing effect of despair, and the power optimism to reverse this trend. The article isn’t available online, but in the post below from my other blog I highlight relevant passages from a Kelsey piece in Smithsonian Magazine on similar themes.

This article is obviously focused on ecology, but is all too true of our healthcare systems. For similar reasons to those Kelsey ascribes to environmentalists who are wary of being overly focused on good news, frontline workers in the health service naturally tend to focus on what is wrong, what is proving impossible, what needs to change. This is necessary, but can become an overwhelming counsel of nihilism, fostering cynicism and very often helping to entrench negative practices.

This is very relevant to the various themes on values, morale, “blame culture”, and possibility of positive change within not only the HSE but any healthcare organisation.

Séamus Sweeney

The current issue of BBC Wildlife Magazinehas a fascinating cover story by Elin Kelseyon hope and optimism versus despair in how we think about they environment. Essentially, much media discourse on the environment tends to be gloomy, doom, and generally despairing. Kelsey cites a wide range of research on how this negativity effects how we think about the environment and our beliefs about what can be done – and therefore what is done – to improve things. The full article is not available online. This article from Smithsonian Magazine is briefer, but captures her idea:

Things are far more resilient than I ever imagined. Me, green sea turtles, coral reefs blown to bits by atomic bombs. In a twist of fate that even surprised scientists, Bikini Atoll, site of one of the world’s biggest nuclear explosions, is now a scuba diver’s paradise. Bikini Atoll located in the Pacific’s…

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Leandro Herrero: “A team is not a meeting”

 

Another wonderful reflection from Leandro Herrero, this time I am being more selective in my quoting…:

 

One of the most toxic practices in organisational life is equating ‘team’ and ‘team meeting’. You could start a true transformation by simply splitting them as far apart as you can and by switching on the team permanently. In a perfect team, ‘stuff happens’ all the time without the need to meet. Try the disruptive idea ‘Team 365’ to start a small revolution.

In our minds, the idea that teams are something to do with meetings is well embedded. And indeed, teams do meet… But ‘the meeting’ has become synonymous with ‘the team’. Think of the language we often use. If there is an issue or something that requires a decision and this is discussed amongst people who belong to a team, we often hear things such as, “let’s bring it to the team”. In fact, what people mean really is, “let’s bring it to the meeting. Put it on the agenda.” By default, we have progressively concentrated most of the ‘team time’ in ‘meeting time’. The conceptual borders of these two very different things have become blurred. We have created a culture where team equals meetings equals team. And this is disastrous.

As a consequence of the mental model and practice that reads ‘teams = meeting = teams’, the team member merely becomes an event traveller (from a few doors down or another country?). These team travellers bring packaged information, all prepared for the disclosure or discussion at ‘the event’.

Friendship and Work in Medicine and Healthcare

In 2001, Digby Anderson wrote a short book, Losing Friends, about what he described as the decline of friendship. This New York Times “At Lunch With” pieces ummarises his argument:

”All past civilizations have declined, and Western civilization is about due to go,” he said, gamely piling his plate with assorted meats and salads. ”The death of friendship is one symptom of that.”

He says he believes political extremism has rendered friends powerless to help one another. Liberals’ insistence on equal opportunity and impartiality, he said, has led to ”egalitarian bureaucracy,” a muddling of what had once been smooth-flowing business networks based on friendships. Years ago, he said, friends happily helped one another find jobs; today they shy away, lest they be accused of favoritism.

”Even though it makes sense to hire a friend, or even a friend’s friend, there’s this feeling that you have to give everyone an equal chance,” he said.

The blow from the right, he said, has been a constant emphasis on the family as the ”repository of all virtues” — and, thus, the only institution worthy of trust and time.

”The ancient Greeks had a better idea: they considered their friends to actually be their family,” Dr. Anderson said.

My recollection of the reasons he gives in the book why “it makes sense to hire a friend, or even a friend’s friend”, is because of the special knowledge which friendship gives us about someone’s true nature. A friend – a true friend – is also less likely to screw over their friend… or at least thats the theory. I wonder how strong the evidence is for the counter argument, that hiring friends is somehow bad?

I am not sure how much I buy of Digby Anderson’s overall argument about hiring friends etc, but there is definitely something in his reflections on the decline of friendship.

The official blurb is also interesting:

“One loyal friend is worth 10,000 relatives”, said Euripides. Aristotle thought friendship the best thing in the world. Saint Augustine was devastated by the death of a friend, “All that we had done together was now a grim ordeal without him”. For men as different as Dr Johnson, Coleridge and Cardinal Newman friendship was a great, moral love. For Cicero it was a foundation of social order. For Burke “good men [must] cultivate friendships”. To try to lead a good life on one’s own is arrogant and dangerous. In past ages business thrived on the trust of friends; armies won battles on the loyalty of men to their comrades and people were attracted to and schooled in medicine, law and academe by friendship. This friendship of the past was high friendship, a friendship of pleasure but also of shared moral life.

LOSING FRIENDS contrasts this high friendship with the “pathetic affairs” which pass for friendship today. Friendship is in trouble. An institution once as important as the family, has been “diluted to mere recreation…passing an odd evening together…sharing the odd confidence”. It is being outsted from business through fear of cronyism and squeezed between the demands of work and the increasingly jealous family. Fathers neglect their obligations to their friends at the club or pub to bath their children. Many of us will have no friends in illness, in need or at our funerals. Bewildered letters to agony aunts ask how to make friends. Schools are absurdly introducing classes on how to do so. Our society has no public recognition of friendship and cannot even discuss it articulately. When it does it sentimentalizes it. Modern society is wealthy, healthy and long lived. Aristotle would ask what the point of such a life is if lived without friends.

I have (or had) a copy of the book somewhere. I read it in around 2004. The message did resonate, and since I have seen how social pressures that tend to squeeze out friendship intensity.

Healthcare in general, and medicine in particular, is on one level a fertile ground for friendship. One ends up spending a lot of time with other people engaged in what is  a highly intense, demanding role. It is natural enough for some strong bonds to form, as over the hurried coffees and lunches some small talk is exchanged. There has also been a boozy culture around medicine in the past at least, and while one could make many observations on the role of alcohol as a form of self-medication, there was a social side to all this.

And yet the structure of medical training in particular is not conducive to longer term friendships. One spends three, or six, or at most twelve months in a post as a trainee  doctor. The intense friendships of one rotation are suddenly severed. With the best will in the world, and my sense is the unreal interactions of social media have exacerbated rather than ameliorated this, it is hard to keep up. And when one completes training, the camaraderie of the res room is something that is closed to you.

The factors that Dr Anderson discusses – the suspicion of anything that might hint of favouritism, the dulling bureaucratic managerial discourse of healthcare management, a sort of idolatory of the family now as much a left as right wing feature – are present in medicine too.

How does friendship relate to the issues of morale and a healthy work culture I have blogged about before? The importance of “psychological safety” in team interactions is emphasised in Google’s Project Aristotle as key to successful team interactions. Fostering a sense that teams can communicate openly, without fear of recrimination or embarrassment, sounds to me very much like fostering friendship. Of course, perhaps this is falling into some kind of trap where friendship can be subservient to the interests of an organisation, and indeed denigrating friendship as something that needs to be justified in pragmatic, utilitarian terms.

Unintended consquences and league tables

I have just finished Simon Westaby’s memoir Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table . This is for a review which will follow in due course. The main focus of the book is on the stories of the patients and the surgeries themselves, some passages have a (literal) heart-stopping intensity.

One recurrent theme, towards the end of the book especially, is the deleterious effect of blame culture and league tables on surgical practice. Prof Westaby, it turns out, wrote a recent paper on surgeon’s perception of this:

National Survey of UK Consultant Surgeons’ Opinions on Surgeon-Specific Mortality Data in Cardiothoracic Surgery

Abstract

Background—In the United Kingdom, cardiothoracic surgeons have led the outcome reporting revolution seen over the last 20 years. The objective of this survey was to assess cardiothoracic surgeons’ opinions on the topic, with the aim of guiding future debate and policy making for all subspecialties.

Methods and Results—A questionnaire was developed using interviews with experts in the field. In January 2015, the survey was sent out to all consultant cardiothoracic surgeons in the United Kingdom (n=361). Logistic regression, bivariate correlation, and the χ² test were used to assess whether there was a relationship between answers and demographic variables. Free-text responses were analyzed using the grounded theory approach. The response rate was 73% (n=264). The majority of respondents (58.1% oppose, 34.1% favor, and 7.8% neither) oppose the public release of surgeon-specific mortality data and associate it with several adverse consequences. These include risk-averse behavior, gaming of data, and misinterpretation of data by the public. Despite this, the majority overwhelmingly supports publication of team-based measures of outcome. The free-text responses suggest that this is because most believe that quality of care is multifactorial and not represented by an individual’s mortality rate.

Conclusions—There is evident opposition to surgeon-specific mortality data among UK cardiothoracic surgeons who associate this with several unintended consequences. Policy makers should refine their strategy behind publication of surgeon-specific mortality data and possibly consider shift toward team-based results for which there will be the required support. Stakeholder feedback and inclusive strategy should be completed before introducing major initiatives to avoid unforeseen consequences and disagreements

This was reported in the Daily Telegraph as follows:

Patients are dying because heart surgeons are too worried about their mortality ratings to operate on critically ill people, a major study has found.

One surgeon claimed he had a watched a three-year-old child die waiting for a valve replacement because a doctor was “too chicken” to operate because of the potential risk to his reputation.

Another warned that surgeons had “become experts in running away from difficult cases”.

 Patients have been able to see league tables showing how well doctors perform on an NHS website since 2014, while information about individual heart surgeons has been available for a decade.

But nine in 10 heart surgeons claim that publishing individual data has led to blame culture where the sickest patients are denied treatment for fear it will lead to an investigation if they die in theatre.

Research carried out by doctors including Stephen Westaby, of the John Radcliffe Hospital in Oxford, and Professor Lord Darzi, chair of surgery at Imperial College and a government adviser, found nearly 60 per cent of surgeons said they were opposed to the current system.

Some 87 per cent of the 264 heart surgeons who replied to a survey said that publication of surgeon specific mortality data had caused a “risk averse” culture in the NHS.

Report author Dr Westaby said: “We have been trying to establish what has been happening among colleagues for some time now. It’s so damning you can hardly believe [it].

“Doctors won’t see a patient if they think it will be a risk to their reputation.

“And it’s often the guys that are doing the sickest patients who end up with the worst scores, because their patients are more likely to die.”

One wrote: “Decisions have become about protecting me, not about what is best for the patient. This is a terrible form of medicine to practice. There is no dignity at the end of life, with surgeons delaying inevitable adverse outcomes in the hope of a miracle or transferring patients to other units so that they don’t count in the figures.”

Another said: “When previously surgeons would have been willing to give it a go on a patient who was certain to die, as there as nothing to lose, now they will be concerned that there is quite a lot to lose.”