Ethics and toxic high-workload work environments

[摘要] Work environments might be considered toxic because of lack of support or because of undermining or intimidating behaviours of work colleagues. In this article we also consider the situation where the workload is too high to feel safe. Such environments may be aggravated by there being no support or opportunity to influence workload allocation, causing greater work-related stress. Workload is the most important factor contributing to stress.1 Other factors include bullying and harassment, discrimination, lack of resources, conflict, and dealing with pain and suffering.2The effect of slowly increasing work pressure is that, because of their understanding of their ‘duty of care’, doctors make micro-adjustments to their behaviours and work practices to cope with the increased work. This acceptance of the increased workload has two main effects: it sets a new level of patient expectation; going the ‘extra mile’ becomes expected, ‘just another mile’, with a further mile being ‘extra’.3 Also, because some of these micro-adjustments are to cease activities that help maintain doctors’ wellbeing (such as spending time with friends, doing exercise, and pursuing interests) they harm doctors; by the time doctors realise that they have a problem, they may have already been seriously harmed by the system (the ‘boiling frog’ effect) and may be close to (or already at) burnout.Much of the focus in the NHS currently is on the need for doctors to be trained in ‘resilience’ — which may imply to doctors that the problem is not with the system but rather with their lack of coping mechanisms. We argue that this is misguided, and the focus of attention should change.SOME PRINCIPLES APPLIED Beneficence4 — while it is important to ‘do good’, there is sometimes an assumption that doing anything is better than doing nothing. Non-maleficence4 — the prevalence of presenteeism5 when doctors are unwell suggests that this principle is largely overlooked, potentially putting patients at risk.6 This may also put clinicians at risk through stress, poor performance, overwork, burnout, or disciplinary action. This can be expressed as a duty to work safely — The General Medical Council’s (GMC’s) Good Medical Practice7 emphasises patient safety and the need for patients to be treated to a high standard and in a timely fashion, but says little about protecting the health and wellbeing of the doctor or the potential danger to patients from overworked doctors.8 Little is said either about the duty to be brave enough to escalate issues so that the responsibility is not completely assumed by the frontline clinician.

[学科分类] 卫生学