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Hello, I’m Domhnall MacAuley and welcome to this BMJ Leader conversation. Today I’m talking to Nicki Macklin in New Zealand. It’s the dark midwinter here and a beautiful sunny morning in New Zealand. Thank you very much for joining us today Nicki. Let’s take you back to the very beginning. Tell us about your school days and what brought you to your career.
Nicki Macklin: There was nothing very remarkable about my school days other than that I had a brain injury as a teenager. And that does kind of influence your life choices in a way. I had a brain injury, had rehabilitation for a couple of years and during that time the occupational therapist who had worked closely with me made a huge difference in my life.
And without advocating and pushing for me, especially within my school environment, there’s no way that I could have gone on to university. She believed in me, and she pushed me, and that sent me off into occupational therapy training. She was the first one that said “you’ve had all this experience, it would be amazing for you to be able to put that into use. You understand what people are going through and how hard it can be”. So I went into Occupational Therapy training and loved it. And, it will be no surprise that I went into brain injury as a specialty area. I did that for a number of years and really loved it. Then I went into public health training, which I also loved, and it gave me the bigger picture view of the system, how it works, and some of the policies and practices that I followed day to day as an occupational therapist. After a time I moved further into primary health care and public health, implementation, and quality improvement.
DMacA: Let take you back to your work as an occupational therapist, because your personal experience must have greatly influenced your work.
NM: I think it made me a much better advocate and I was able to build a really close rapport with my patients and their families. It was nice to be able to turn up at someone’s home, where their whole world has changed and shifted on its axis due to injury, and be able to genuinely and authentically say, I can understand a little bit of what you are going through, its going to be okay, and I’m here to help.
Keeping with that theme of lived experience – by the time I’d left my work to have children, I had been working in primary health care for some time- one of our children developed quite complex medical needs. It was this experience, again, of being in the system, having to advocate, and push and navigate multiple systems, that really got me interested in the work that I’m now doing, this kindness and health care work. Coming around full circle, it was this experience of the system myself with the brain injury, and then having worked in the system as a health care professional. I’d done some policy and service implementation work and now back into the system with my own child this time, I became really curious as to the impact that kindness has on patient outcomes. As a family we noticed the presence and absence of kindness in our care, and coupled with my healthcare professional background, I could understand those times kindness wasn’t so present. I could understand that it’s not always an individual’s choice in terms of how kind they can be because there’s a whole system behind you and a whole range of influences and forces that impact on individual behaviour. I wanted to couple all of those experiences, and make some sense of why we act the way that we do in the healthcare system and what gets in the way of us being able to act the way that we want to act.
DMacA: You’ve spoken about your personal experience with your own child, but also in that context, you’ve talked about dysfunctional teams and how that influences care.
NM: We noticed in the care of our family that there was an impact in terms of the presence or absence of kindness when it was directed towards us. It was the small everyday acts that health care team members showed us that made a huge and disproportionate difference to how we perceived our experience and our care. But, more than that, it was the presence or absence of kindness within the health care team, witnessing how members were working together, how they were communicating and talking to each other, whether they were undermining each other, or offering us conflicting treatment advice, that had a much greater impact on our experience than any kindness shown directly towards us. So, in terms of our experience and trust and the people providing care to our daughter, how the team were relating to each other was much more important to us than how they were relating to us.
DMacA: Kindness is such a generic term but you’ve reflected on a very personal experience and you’ve spoken about incivility in the teams and how that can affect care. Talk to us further about that.
NM: We’d noticed that anecdotally, but my research work led me to take a deep dive into the literature and the research around incivility in health care. And it was really shocking. We have this perception of kindness as being soft and fluffy, and at times it’s weaponized, as being – how we can fix health care, how we can solve the health care problems that we have with kindness? That’s unrealistic! But many studies have shown that incivility is the root cause of up to three quarters of all patient adverse events in hospital care around the world.
There are really serious concerns around incivility. It’s not even bullying. Incivility is just garden variety rudeness, eye rolling, turning away from one another, undermining each other, being passive aggressive, all that stuff that we come up against a lot inside workplaces, not just in healthcare. Incivility has a huge impact on measurable outcomes of patient safety.
DMacA: Kindness is a very generic term and I’d like to focus in on this a little. What is the difference between kindness, empathy, and compassion? We often get those all mixed up.
NM: Getting into research, we had these really grand ideas about how we were going to research kindness; how we were going to do some longitudinal studies, follow junior health care professionals for a couple of years and map at their experiences and interactions with their teammates. We quickly realized that we couldn’t do any of that because there wasn’t a single well-established definition of kindness in the health care literature. So that presents its own problem with how we can measure or research something if we can’t define it.
We wound things right back and realized that the very first step we had to try to accomplish was to build a definition of kindness. The best way to do this is to compare and contrast with similar or related terms and we noticed in the literature that kindness is often confused and conflated with empathy and compassion, so we chose those as our priority terms for comparison. We found that there are differences. Kindness should not be confused with compassion or empathy and vice versa. They are separate terms that deserve their own place in the literature. They all have a contribution to make and deserve to be appreciated as standing apart from each other and we describe this in our BMJ Leader paper.
https://bmjleader.bmj.com/content/8/4/293
Macklin, N., Wilkinson-Meyers, L., & Dowell, A. (2024). Kindness: Poor cousin or equal kin to Compassion and Empathy in the Healthcare Literature? A Scoping Review. BMJ Leader, leader-2024-001034. https://doi.org/10.1136/leader-2024-001034
DMacA: Having made us all aware of the importance of kindness, and defined kindness, I know you’re interested in how we teach kindness…
NM: For a long time we’ve talked about compassionate training or empathic training. When our healthcare system is under so much pressure around the world, with 50% of our global workforce showing signs of burnout, that’s really serious. When you look at just nurses and doctors, that figure goes up to 66%. Two thirds of our global nursing and doctor workforce are showing clinical signs of burnout, so I think we need to be careful about what we’re asking our healthcare professionals to do. We need to be careful when we’re talking about showing compassion to other people suffering and asking healthcare professionals to emotionally dial in to their patients and to engage in their suffering in every interaction. That’s a lot to ask. And, that is a known risk factor for compassion fatigue which renders you unable to show compassion and engage emotionally with your patients. You can burn yourself out.
Whereas kindness, because it can be proactively decided and you don’t have to ask someone to hit that strong emotional reaction but merely to act in ways that demonstrate caring and show that other person respect and preserve their dignity, which will be perceived by the patient as very kind or perhaps even compassionate. We can ask that of our health care professionals. It’s like a muscle. You can train for kindness. Some of my fellow kindness advocates get a little bit prickly with this idea because they think it insinuates some sort of form of tokenistic or performative kindness. But, that’s better than not showing any kindness, or being rendered unable to show compassion because you’re so burnt out.
But, going back to thinking of kindness as being like a muscle, it may feel a little bit performative at the start, but the more you do it, the more natural it becomes, the easier it becomes, and it becomes a habit. I do believe, and putting my patient advocate hat on here to say this, I do not think it is unrealistic to expect kindness in a health care setting, both between health care team members, and also to patients and families. It is not an unrealistic expectation and I think we need to be finding ways to embed kindness as a highly reliable value in our health care systems.
DMacA: You’ve spoken wearing your patient advocate hat, and I know from your own experience that things can go wrong, and you’re also involved in restorative initiatives. Tell us more about that.
NM: I am on the board as a patient representative but I also feel very keenly for the project because of my health care professional background. When any sort of harm happens in a healthcare setting it’s extremely hard and very traumatizing for our patients and their families when something goes wrong but, with our current processes which are punitive, it is also extremely hard on the healthcare professional in that situation. They’re often taken through processes where there’s a lot of individual blame that doesn’t recognize how the system has interacted to create a situation where harm has been able to occur. So, whether it be through a lack of supervision, or unsafe working conditions, skeleton staff, not having a back-up team, having a psychologically unsafe environment where you can’t, or you’re not comfortable, asking for help so you proceed anyway, even if you’re not sure what you’re doing. There are all these systemic influences that lead to health care harm. And yet our disciplinary processes try very hard to lay that blame on the individual. It’s not often that the influence of the system is fully recognized. And again, that’s very hard on the healthcare professional. It’s also not a transparent or realistic process for the patient and family to go through either. It’s not helping them to understand how the system interacted that led to the harm. And if we’re not acknowledging the systemic processes behind healthcare harm, then we can’t adjust them. We can’t improve systems if we’re not reporting or dealing with them in a holistic way.
The work here is to create a situation that, when healthcare harm instances happen, there’s a process that you can go through that respects both the healthcare professional as well as the patient and family, it’s about getting people in the same room and sharing the power in terms of being able to share their perspectives and their stories, being listened to, and having that process worked through in a way that restores people’s dignity, what we call in New Zealand ‘mana’, and allows people to move on. It’s trying to remove that punitive approach, and it’s trying to increase democracy, and also the transparency in terms of the role of the system.
The reason that we do it this way is because we know that patients who experience harm often don’t want to see the healthcare professional punished. That’s not why they made the complaint. They don’t want to see the big stick shaken at anyone. They just want the system to change so that it doesn’t happen to anybody else. And the only way we can change that system is if we’re having a really honest and transparent conversation about what went wrong at a socioecological level.
DMacA: When we talk about harm and blame, it tends to move along to litigation. My final question is tricky question, because you are due to speak to the New Zealand Law Society, how do you think that will go down with them?
NM: I’m about to speak to them in March and I’m looking forward to it because I think it’s going to be a hugely different perspective. You’re right and I know, having worked with many health care professionals and also because my husband is a lawyer and knowing a lot of lawyers, there’s also an argument against kindness, in that people feel they have to practice defensively. Yet, here is someone like me saying it’s good to show vulnerability and to let people know your weaknesses as well as your strengths. And, to be patient and understanding that we’re not all strong in the same way, and that being vulnerable is a good thing in a team. And then you have people, consultants and lawyers, who say “That’s fine but I have to practice defensively because if I show vulnerability, it might lead to a complaint. If I don’t come across as knowing what I’m doing, then how will the patient trust me?” That’s not really founded on science. We know from studies that trust is enhanced when people show vulnerability, and trust and confidence in the process are enhanced when people are open-hearted or show a human side in their interactions. It’s a really interesting question and I’ll have to keep you posted on how it goes with the Law Society. I’m really looking forward to hearing some different perspectives.
DMacA: Nicki, it’s been just fabulous talking to you. Thank you very much for sharing so much of your personal life, your professional life, and some great insights into the patient perspective and kindness most of all. Thank you very much indeed.
Scoping review 2024: https://bmjleader.bmj.com/content/8/4/293
Macklin, N., Wilkinson-Meyers, L., & Dowell, A. (2024). Kindness: Poor cousin or equal kin to Compassion and Empathy in the Healthcare Literature? A Scoping Review. BMJ Leader, leader-2024-001034. https://doi.org/10.1136/leader-2024-001034
Patient voice 2022: https://pmc.ncbi.nlm.nih.gov/articles/PMC10241029/
Macklin, N., Morris, C., & Dowell, A. (2022). Hearing the patient voice: a qualitative interview study exploring the patient experience of a nurse-led initiative to integrate and enhance primary and secondary healthcare pathways. Integrated healthcare journal, 4(1).
BMJ Commentary with the gang 2023: https://www.bmj.com/content/382/bmj.p1505.full
Bailey, S., Allwood, D., Macklin, N., Montori, V., Bisognano, M., & Klaber, B. (2023). Healthcare education needs radical reform to emphasise careful and kind care. BMJ, 382
Nicki Macklin
Nicki is an occupational therapist in New Zealand with a long history of engagement with primary healthcare service design and implementation. From her lived experience she developed a particular interest in the clinical communication and in how teams work. She acts as a patient advocate on several local and international boards and foundations and is an associate editor at BMJ Leader.
She has worked with many different organisations to help them understand how to build their capacity for kindness at all levels of their workforces and systems and does not tolerate the perception of kindness as a soft or discretionary skill in healthcare. Nicki has recently submitted her PhD at the University of Auckland’s Medical School.
Nicki is interested in all things kindness, and in speaking, researching and writing about kindness in healthcare.
Professor Domhnall MacAuley
Domhnall MacAuley currently serves on the International Editorial Board for BMJ Leader.
Declaration of interests
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.