Feature

Smile Please !

The morale of healthcare employees can directly affect the quality of service and customer care being provided. However, have Indian hospitals started to view morale boosting measures as seriously as they need to? Finds out Sonal Shukla

In an interesting study done by largest research organisation in the world specialising in mental illness, the US based National Institute of Mental Health, at least one in four employees in healthcare endure an episode of significant psychological illness during their prime working years and in any given year, more than one in 10 will experience clinical depression. Moreover, for some occupational categories the risks are even greater. Physicians, nurses, chiropractors, health technologists and dentists have higher-than-average suicide rates. Health technologists, licensed practical nurses, clinical laboratory technicians, nurses aides, registered nurses and dental assistants had among the highest rates of hospitalisation for mental disorders in one study of 130 job classifications. While there are no official estimates for Indian healthcare employees, but indeed they would indeed share the same story.

As levels of competition have grown manifold, there is a pressing need to give a lot of emphasis on the quality of service which has translated into greater stress for all healthcare staff. The uniqueness of this industry is that employees are forced to face the stark realities of life and death, 24x7, under tremendous physical exertion, irrespective of time, date or day or of any turbulence in their own personal lives. Any lack of effective and timely efforts in keeping employee spirits and morale high therefore leads to a steady dip in their performance. Says Dr BK Rao, Chairman, Sir Ganga Ram hospital, New Delhi, "HR managers, particularly those responsible for healthcare facilities, face a major daily challenge in boosting the morale of all staff. Research on motivation has shown us that if you want to improve the experience of patients and the reputation of your service, pushing already motivated people to become even more so is crucial."

However, an averagely intelligent HR audit can immediately diagnose this drop in productivity, according to Shrabani Basu, Management Consultant and Corporate Trainer, This is because, it is only to a certain extent, possible to truly 'cure and care' for a patient in all its entirety, only by technical brilliance. A huge chunk of the patients' well being largely depends upon the mental and emotional makeup and well being of the employees of a hospital, that are directly reflected in their concerted emotional and behavioural efforts towards patients. "We all know, in hospitals, it is very important that a patient has to be taken to a high level of 'feel good' domain, which actually affects his responses to drugs and clinical processes towards recovery. To attain this very difficult task of making a patient feel very assured of being well taken care of clinically, is actually largely dependant on his emotional well being along with clinical excellence," she adds.

Pressing Need

The healthcare staff constantly faces tremendous physical and emotional pressure and the nature of the industry makes it even more extracting. Doctors and healthcare staff are not only under pressure from a professional point of view but also psycho-socially as patients and their family members share with them their concerns and grief. While this kind of interaction does give a special dimension to the relationship, but the fact remains that it takes a heavy toll on doctors and healthcare workers. Malcontent employees can even create a sense of gloom and doom in the workplace. In many cases their negative attitude can get transferred to other staff members and bring about low productivity. "The morale of all healthcare workers is especially important since they are dealing with human lives. It also has a direct impact on patients who are already in a troubled state of mind and tend to be more susceptible and affected by the attitude of the healthcare worker dealing with them. Hence, morale boosting becomes extremely essential for a healthcare worker," states Suyash Borar, COO, BM Birla Heart and Research Centre (BMBHRC), Kolkata. Incidentally, healthcare workers, irrespective of their professional stream, are trained and mentored from inception to keep a safe distance from letting the impact of this relationship affect their professional judgment and thereby their overall productivity. However according to experts demarcation between the beneficial involvement with the patient and/ or family for treatment and rehabilitation purposes and cross over to the limit which affects the healthcare staff itself is quite thin; and it is here that they have guard themselves against such possibility." Generally, the care provider scheduling, is done in such a manner that person's duty schedule should avoid building any disturbing relationship between him/ her and the patient. However it is easier said than attained. After all, the staff are also human, it is the humane angle which is playing a predominant role at this juncture." opines Dr Praneet Kumar, Chief Operating Officer, Fortis Escorts Hospital, Jaipur and Director - Quality Assurance, Fortis Healthcare Limited. Therefore in addition to scheduling, seniors in each stream who are sensitive and mature enough to sense any such situation very early, usually intervene. The intervention could be just a simple counseling session(s) for the affected staff to removing the employee from the care giver team or even forced leave of absence at times. All the above actions help prevent or at least minimise any chances of productivity decrease of the individual staff. "What is more important here is the quality of decision making that needs to be protected and therefore it becomes important to institute mechanisms that do not allow the staff to drift into developing emotional relationships that can be counterproductive," adds Dr Kumar.

Morale boosting methods also can go a long way in helping retain the staff. "Issues like attitude of managers towards their subordinates, working conditions, pay, safety, feeling of unfair treatment, lack of recognition, fear of superiors, if all these issues can be dealt intelligently we will definitely be able to retain our employees," feels Anthony Handa, Manager— Personnel, Ruby Hall Clinic. While it is a reality that healthcare staff is currently suffering from a sort of 'compassion fatigue,' not many groups are focusing towards morale boosting. But nevertheless, there are Groups who have taken a small yet positive step forward in this direction. Jaipur based Fortis Escorts Hospital is a case in point. It has created social forums that outline and formulate indoor and outdoor sports activities that are regularly utilised by all, without any differentiation between staff categories. While, this helps in de-stressing the staff, it also helps team building and bonding. The hospital initiated ten day sports meet from this year which the staff managed to attend even after performing their primary duties. Similarly, the entire staff of the hospital was gifted a souvenir— a silver coin with the name of hospital and date of first anniversary as a token of remembrance. "These are few of the activities that we have undertaken that affects the entire staff. Actually, morale boosting activities or for that matter any such intervention for development of soft skills has to remain responsive to changing dynamics and we at Fortis Group invest a lot of time and resources to enable it," shares Dr Kumar. Like Fortis Escorts, there are others like Kolkata-based BM Birla Heart Research Centre, Jaslok Hospital and Research Centre, Mumbai; P D Hinduja Hospital, Mumbai; KG Hospital and Post Graduate Medical Institute, Coimbatore, Max Healthcare in Delhi, Bangalore based Global Hospitals who feel that morale boosting in healthcare is the need of the day and have taken steps to implement some noteworthy measures in this area.

Determining Factors

Let's face it. A hospital is indeed not a 'pleasant' place to work and work environment plays a significant role in either increasing or decreasing the pressure that surrounds the healthcare staff. The work force finds themselves under pressure due to many factors such as performance and productivity targets, patient satisfaction scores, top-line and bottom-line, competition performance edge and overall patient engagement scores. Other determinants of work force pressure are lack of knowledge or experience of handling pressure situations in a healthcare setting, aberrant behaviour as a result of increasing expectations of patients and their families with regards to treatment outcomes, increasing violence in healthcare facilities, inter-personal relationships within the stakeholders of the provider staff, lack of communication leading to situations that become unpleasant, changing value systems of society along with overall environment and its dynamics that has become more materialistic. "Work load can be unpredictable and hence result in long working hours. Shift duties always pose a challenge in trying to adjust individual needs." opines Dr Shubnum Singh, Chief Medical Affairs (External), Max Healthcare, New Delhi. The other reason that contributes to work-force pressure is the way communication is done. Many hospitals are increasingly finding themselves at the receiving end of 'patient rage.' Apart from higher expectations from the patient's end, there are many internal factors that escalate the work pressure. "Reasons that come to the top of my mind are non-clarity of job descriptions , lack of efforts in induction and orienting employees to explain niche areas like ways to handle 'overlapping' of duties or the need to multitask, crisis management and conflict resolution. Lack of rewards and recognition of the desired performance and lack of clarity on career progression in the organisation is also a crucial factor" states Basu. Hospitals across the country are being expanded and new services are being set up on a continuing basis. All too often, there is no proportionate addition of resources to go with the new services. The existing doctors and staff members are made to work extra hours. Little consideration is given to ensure if they can cope up with this extra work. "In many hospitals, there is shortage of senior doctors and hence there is inadequate supervision and on-call support. Obviously junior doctors are forced to take up extra duties which they are not competent in doing and this result in stress," states Dr G Bakthavathsalam, Chairman, K G Hospital and Post Graduate Medical Institute, Coimbatore. Doctors are also required to spend time on paper work, namely filling up insurance forms, replying to letters, engaging in research projects, making presentations, attending conferences and clinical meetings. Many hospitals do not have adequate space for doctors to sit and relax. Col Manesh Masand, CEO of Mumbai based Jaslok Hospital points out some other infrastructural limitations adding to stress levels in Jaslok Hospital. "In my Hospital work-pressure is high due to higher turnover of nursing staff."

Gender and Stress

Having known the fact that stress is a part and parcel of the work environment which healthcare staff faces everyday is there a variability in the kind of pressure faced by the male and female staff? How far is this hypothesis relevant? The reaction to this query was an interesting mix of agreement and denial. According to Basu, to a large extent this hypothesis is not relevant. Echoes Borar. "However, lady employees are encouraged due to their high levels of ownership and service orientation given the Indian socio-cultural scenario." As women increasingly gain occupational mobility, they are not only exposed to the same physical hazards of work environment as men but also exposed to the pressures created by multiple role demands and conflicting expectations. By fulfilling their economic needs, employment has no doubt made women independent with an identifiable social status but it has also made them to juggle into two main domains of life- work and family. Says Dr Kumar, “There is definitely variability in the kind of pressure faced by different genders. However, it is also affected by the job function of that particular employee.” He cites an example of nursing staff which is predominantly female. "Females are perceived as more sympathetic and considerate and therefore patients and their families share more information about their concerns and illness with them rather than doctors at times. This leads to undue burden of responsibilities on the shoulders of the nurses and those who are more prone to get emotionally involved are affected due to the stress thus created in their minds," opines Dr Kumar. There are some who perceive that men are lesser 'emotional' beings who manage to cope up stress better than their female counterparts because of their objective outlook towards situations. Says Dr Sanjeev Singh, Senior Medical Administrator, Amrita Institute of Medical Sciences and Research Centre, Kochi, "Men tend to have a problem-solving approach which is less coloured by emotions than women. This, perhaps, helps them to deal with stress more easily than women."

While there is a divided opinion over variance in the levels of stress amongst male and female staff, research says that the fairer sex face the blues more. In the US, female workers reported a higher incidence of depression than male workers, which was a trend across the board, regardless of occupation type.

The Mid-life Crisis

It is probably the middle layer who assumes the team leader/ supervisor positions to the upper mid-level/ senior level like the heads of departments that need maximum motivation. This is because these employees are expected to effectively drive key functions and activities in a hospital. The top management (administrators or physicians) work according to the vision of the institution. They set goals and targets. But it is the mid-level worker who has to understand, motivate, train, implement changes and deliver results. They are responsible for taking instructions and guidelines from the top, communicating them and driving actions throughout the organisation. Hence, it is of utmost priority to always keep them motivated so that the organisation's vision is translated into its mission in the best possible manner. Agrees Dr Singh of AIMS, "It is the middle level that requires morale boosting the most, as they face the maximum stress. It is really like midlife crisis, the young are exploring and experimenting and the seniors are settled. It is the middle aged that have more doubts about the past and worries about the future. Similarly, mid-level workers, whether doctors or nurses, need morale boosting the most," he adds. Nurses are also believed to be the most stressed out personnel, since they spend the maximum time with the patients during their hospitalisation. They serve as the face of the hospital for the patients which also means bearing the brunt of any customer dissatisfaction. "Nurses have to deal with maximum service interfaces at the hospital - be it interacting with doctors, technicians, patients, patient relatives and support services which makes their job extremely demanding," says Borar. However, in the opinion of Col Masand it is the class III and IV employees who need maximum morale boosting and motivation from time to time as they are the backbone of the institution. "These employees face problems at work and domestic front, of financial and social security and over-work leading to ill health and absenteeism," says Col Masand. Agrees Dr Bakthavathsalam, " The staff members working in lower categories, namely peons, ayahs, sanitary workers, liftmen, stretcher bearers, cleaners, security guards and sweepers require morale boosting measures the most, because they are subjected to a lot of strain and stress in their work on a continuous basis. They give off their best to the hospital by toiling hard. They do strenuous work which is some times hazardous and also at times detrimental to their health," he adds.

Newer Trends

Experts identify and suggest few innovative trends which could be apt for the needs of the healthcare workers. Some of the newer trends and approaches today, is the presence of an appropriate on-boarding programme, training and development calendar that is well devised, implemented, and audited. According to experts, this must be done with great expertise and precision wherein the findings are translated into action plans and results monitored in detail. "The result is not only imparting knowledge to employees, as thought conventionally, but also sensitising them to the employee needs and organisation needs, making them aware of their strengths and developmental needs and guiding them to build a great career and a good organisation," feels Basu. Multi-skilling is also a very innovative way to raise the morale of employees. Guiding an employee to develop an overall competency is not only his/ her job, but also in related areas gives the person a great feeling of being an important resource in the organisation. When this is coupled with encouraging work atmosphere in terms of good communication, a timely 'pat-on-the- back' for good work, a prompt response to finding a solution to his/ her difficulties creates a great package for retaining high morale. Organising employee wellness programmes, stress relieving tips offered to employees, conducting yoga sessions, offering gift cards or meal vouchers, health screening for employees and arranging conferences at distant places to raise the spirit and morale of all concerned are few of the newer trends.

"Although much has always been written and said about this, I would like to firmly reiterate that any negligence/ non-attention to even the smallest problems arising out of un-uniform or non-transparent practices or management policies, un-clarified processes in terms of recruitments, staffing, compensation and benefits and career management have a long lasting effect almost instantaneously amongst employees in hospitals," believes Basu. Especially in a hospital, a good amount of regular, dedicated and well etched out team activities need to be in place.

Experts agree that people appreciate help and want the hospital management to care about them as individuals. "Today's hospital manager must invest a significant amount of time in advising, counseling, coaching, mentoring, training and listening. Employees who are helped to perform will feel better about themselves and the hospital for which they work," says Bakthavathsalam. Hospital management may also set-up child care facilities for children. The surrounding environment speaks volumes about the hospital, its values and its policies and employees will be more productive when their environment is comfortable, pleasant and efficiently organised for the tasks to be performed. Experts also suggest recognition programmes to boost productivity and morale. "Here, clearly define the selection criteria so that everyone understands the connection between achievements and rewards. Also, do not use the recognition programme as a way to evade payment of increment or salary raise," explains Dr Bakthavathsalam.

In an industry that is truly very 'people' and 'emotions' based, matching salary compensations all the time may not be possible. Long hours, seriousness of the occupation, trauma and crisis management at all times only make things worse. In this kind of a scenario, probably the only way out is to be very deft at handling every employee at the individual level, keeping two-way communication channels open, proving that the management is fair and transparent with everyone and most importantly, securing good employees through performance linked compensation philosophy coupled with visible career growth paths are very important. "I have seen that many employees have been motivated over a long time due to great work relationships, training and development and fairness of the system. This is despite the fact that they are consistently challenged with a choice of bigger compensation packages and higher level jobs elsewhere," shares Basu. According to Dr Rao, performance management systems if properly designed and implemented can change the course of growth and pace of impact of organisations. In the past organisations as well as the HR function have wasted a lot of time by wrongly focusing on performance appraisals rather than performance management. "Organisations should identify the required competencies for the various roles in the organisational hierarchy. The use of a competency based approach provides information to aspiring employees for developing relevant competencies and fulfill their career aspirations," he adds.

Pat on the Back

Awards, fiscal and non-fiscal incentives, sponsoring for national and international conferences and special courses/ training programmes requested / desired by the employees and inclusion in decision making forums form the conventional way of morale boosting in healthcare settings. At BMBHRC, various activities have been undertaken in the past wherein the Hospital has introduced a comprehensive employee recognition and reward system. It takes active acknowledgement and incorporation of employees' suggestions and has started various employee engagement activities like conducting stress workshops, organising extra-curricular activities. The Hospital has aligned individual goals along with the organisational goals with the implementation of balance score card and also sponsor selected candidates for leadership programmes to IIM, Ahmedabad. "One method used by us to boost workplace morale is to create a 'winning team' programme, combining motivational training, goal-setting, and incentive awards, giving your employees something to rally around and root for. When our employees are focused on achieving a goal, a 'feedback effect' develops. As goals are met, a sense of accomplishment begins to set in, staff satisfaction increases and as a result, workplace morale begins to improve," explains Borar. Similarly, Global Hospitals makes it a point to recognise its star employees. "We identify and reward star performance across employee categories. We also do immunisation programmes for all employees, a recent one being immunisation for Hepatitis B. The Hospital also involves family members in social get-togethers and camps," shares Dr Vishal Beri, COO, BGS Global Hospitals, Bangalore.

Challenging Tasks

There are a lot of issues involved in implementing different morale boosting measures in the hospitals today. They could be reasons arising out of demographic, socio-cultural or even business line or size of the hospital. However, a few factors that almost immediately retard this activity in a hospital are inadequate attention/ priority/ commitment to spending time and efforts on employees' wellbeing and developmental needs and constantly excusing oneself on grounds of driving a high crisis industry/ having little time for these activities. The other limitations include non-expert handling of employees, wherein inspite of having great policies in place, very little or no time is spent on implementing them well as well as poor organisation expertise in promptly handling employee doubts/ grievances/ developmental need. "As they say, one discontented and confused employee is reason enough to affect everyone around in a thunder speed. Improper recruitment, staffing or even succession planning may lead to a wide element of demodulation," avers Basu. The mindset and attitudes of introducing anything new, most of the staff taking their work as routine, different sets of ideas making implementation complex, gap between theoretical and practical points during implementation and keeping uniform policies and procedures are also some major limitations.

To overcome those limitations, experts suggest the introduction of democratic processes with involvement of all key stakeholders in the decision making process, implementing decisions in step wise manner and doing a pilot study before going full board on newer processes implementation. Experts like Dr Kumar give the credit to IT and later ITeS industries that broke the conventional barriers of identified measures for morale boosting and those measures today are seeping in all sectors. Healthcare sector also has not remained untouched. However, the sensitivities and sensibilities involved in the sector restrict the adoption of such measures in totality. The focus today is more towards ensuring work-life balance and therefore involvement of families in all such activities has become pretty important. The trends will continue to evolve and change with times and the sector would have to keep on responding accordingly. Hence, in this kind of industry, there is just no room for being negligent on any employee's level of competence, which unlike technical skills cannot be bound by a process driven architecture but is a cumulative result of his/ her level of morale at work. Hospitals, thus have found that focusing on short-term measures for immediate healthcare needs is not the solution. A long-term strategy for the hospital's success must include provisions for keeping employees healthy and safe, improving the health status of all employees and creating a company culture that supports, promotes and actively engages employees in achieving optimal mental and physical health.

sonal.shukla@expressindia.com