Human beings are incredibly complex and we know it is estimated we make between 10,000 and 40,000 decisions a day. For many of our frontline staff faced with the Pandemic, there has been a need to multiply the number of critical decisions they make each day. This is in the context of their own very human reactions to the situation: fear, grief, frustration and exhaustion. Clearly this is challenging for individuals and the wellbeing of each and every person is important, but what could it also imply for the system in terms of possible impact and what might that mean for how we organise ourselves and lead in future? In particular, how do we balance the directive, ‘heroic’ leadership legitimately required, in part, during a crisis with a model of distributed leadership that retains psychological safety for individuals and enhances decision making? It is heart-warming to see the public gratitude directed at health and care staff, but by constantly calling them ‘NHS Heroes’ are we creating a disconnect between the public narrative and the model of leadership we want to see in the NHS? The Collins Dictionary definition of hero is ‘someone, especially a man, who has done something brave, new, or good, and who is therefore greatly admired by a lot of people’. Arguably not a good fit with our aims to build shared and compassionate leadership.
Decision fatigue is a concept first established by Baumeister (1988) based loosely on the Freudian concept of the ‘ego’. The mental energy associated with ego, he argues is finite and as more decisions are required, a process of ego depletion occurs. This was famously demonstrated by a study of judges who presided on a Parole Board. Towards the end of the day, they released less prisoners even where other contributory factors were the same or more favourable. Decision fatigue leads to a propensity to make safe decisions or decision avoidance. This is further explored by Kahneman (2011) in his seminal work on behavioural economics. He introduces the concept System 1 and System 2 thinking. System 1 is automatic and is characterised by little voluntary control whilst System 2 thinking requires mental effort and he argues is ‘often associated with the subjective experience of agency, choice and concentration’. In other words, active choices take energy and are draining. He also suggests that in terms of the heuristics we use to inform our judgements, we have a natural inclination to risk aversion.
So as NHS clinicians and social care staff work gruelling 12 hour shifts, could decision fatigue be at play and how do we counter it? There is evidence from a number of sources including from analyses of the Cold War policy makers that in a crisis, decision fatigue does impact and create situations where even highly trained professionals make poor decisions. Those individuals are not to blame; they are displaying a basic cognitive process which if it is to be mitigated against needs active and mindful address. If we do this, we could improve outcomes for patients and citizens.
So what can help individuals to reduce the impact of decision fatigue? One answer lies in process. By automating process, we reduce the number of decisions individuals have to make and take away the cognitive burden from individuals. The many Rapid Guidelines produced by NICE related to Covid-19 are a good example of this.
The other important protective factor is taking time for human connection and asking others for their opinions and thoughts. Collaborative decision making reduces the risk of personal bias and reduces the cognitive load on any one individual. The adage ‘it’s good to talk’ really could be the answer.
When staff are busy, there is a risk that human connection in teams is reduced. Arguably it is all the more important at these times that staff take time to connect, reflect and engage in collaborative decision making with their colleagues. The Buurtzorg Model has been viewed with interest and adopted in parts in the UK, developed originally to reimagine care provided in neighbourhoods in the Netherlands. One of their catchphrases is ‘humanity over bureaucracy’. Effective teams are adapting to further improve good decision making. In a very recently published article a Buurtzorg leader is quoted as saying ‘We are learning from each other, cutting out doing unnecessary things and discussing which decisions need to be centralised and which decentralised’
If we consider the main tenets of this model, including the importance of values and factors such as high level of autonomy and positive relationships with others, we find these are highly attuned with many models of psychological wellbeing. Taking some of the principles of dialogue and collaborative decision making and designing care delivery to fit with this feels like it could be a win: win, supporting both individual resilience and better clinical decision making.
In the immediate aftermath of Covid-19, there will be real reflection in terms of how the service has worked and, rightly so, a celebration of how individuals have crossed boundaries, supported each other and provided high quality care in extremely difficult circumstances. It will be interesting to also reflect on how clinical teams have worked together and made collective decisions through this time. It may well be that the teams that have managed to maintain this are the new definition of heroes.
Baumeister R et al (1988) Ego Depletion: Is the Active Self a Limited Resource, Journal of Personality and Social Psychology, Vol 74, No 5, 1252-1265
Kahneman D, (2011) Thinking Fast and Slow, Penguin Books, London
Martin B, Self-managed neighbourhood care in a global pandemic: how is Buurtzorg doing? March 27th 2020, viewed on 3rd April 2020 https://buurtzorg.org.uk/self-managed-neighbourhood-care-in-a-global-pandemic-how-is-buurtzorg-doing/
Rita SymonsRita spent over 20 years in the NHS having started her career in Public Health. Her NHS career covered provider organisations, PCTs, Strategic Health Authorities, a brief stint in social care and included ten years at board level. In 2016 she left her role as a CCG Accountable Officer to set up a coaching and leadership development practice. She is a Senior Practitioner Accredited Coach and is a member of the NHS Leadership Academy Faculty, working on programmes such as the Nye Bevan and Rosalind Franklin programmes. Her interests are coaching, personal agency, leadership development, system leadership and diversity and inclusion. She is passionate about the role of coaching, both at individual and team level and is currently President of the European Coaching and Mentoring Council UK.Rita is a Member of NHS Leadership Academy Faculty and an Associate for PCC.