Institutional Betrayal vs. Courage
The pandemic has brutalized health care such that the term “institutional betrayal” (IB) is becoming part of the physician vernacular. This cringe-worthy term is being used to point a finger of shame at health care leaders and systems who presumably are failing to support and protect their workers adequately. Indeed, we depend on our employers for our safety and well-being. With staffing shortages, lack of supplies and lower revenue, employees bear the brunt of the fallout. Such circumstances might be acts of betrayal of trust and confidence or moral standards are violated. Betrayal often includes feelings of abandonment, frustration, anger and retaliation, with blame directed toward leaders and circumstances beyond our control. If we only place blame, we distance ourselves from attaining institutional/employee harmony more than ever before.
IB was defined in 2008 by Jennifer Freyd, PhD, as wrongdoings perpetrated by and committed within the context of an institution when there is a reasonable expectation of protection for individuals dependent on the institution. Both action and inaction can lead to psychological and physical distress, employee time lost, increased turnover, lack of engagement, medical errors and decreased patient satisfaction. IB manifests with anxiety, dissociation, inefficacy and trauma-specific symptoms, all features reminiscent of burnout. Systemic contributors include excessive work hours, work-related stress and lack of autonomy. These issues, along with the most egregious misconduct, such as failure to prevent or respond supportively to sexual harassment and assault, and violations of diversity, equity and inclusion, contribute to institutional betrayal trauma.
The solution to IB lies in “institutional courage (IC), which is a commitment to seek the truth, persevere and engage in moral action, despite the unpleasantness, risk, and short-term cost. IC is a compass oriented to the common good of individuals, the organization and the world, resulting in more accountable and equitable action. A courageous employer provides a safe, empathetic work refuge, free of shame and judgment, conducive to innovation, career growth and development.
Even if this state is desired, the shift toward IC can be affected by institutional irresolution due to staff changeover, slow implementation of policies and management tactics or lack of funding and resources. Also, an organization’s mission and vision statements can be founded in IC.
Yet, these truths may not be walked out daily by all employees, managers and leaders because time is short. We are overburdened with work, so we objectify one another. Our words and actions are often guided by reactivity. In other words, achieving IC still depends on imperfect, albeit good-intentioned, humans who must choose to continuously strive toward courageous action.
Wellness programs and promoting resilience in the workplace may ask employees to remain overly tolerant of unpleasant or counterproductive circumstances. Rather than pushing for change — either through a job change or fighting for improved workplace conditions — some employees will choose to endure stress and perhaps even abuse.
Policies that put the entire onus for mitigating burnout on the individual may alienate workers. Thus, we face a conundrum: systemic issues that are slow to change, suffering employees who are under-equipped to deal with mounting stressors, wellness programs that promise solutions but underperform, and feelings of betrayed due to lack of positive, forward progress. Ouch!
The advisory board recently shared that an employer of choice should provide meaningful autonomy, ample time to complete work, and seamless support to providers. What does this mean? Autonomy can be supported by providing flexibility and choice whenever possible, ensuring that changes and decisions within the system are well-communicated, transparent and fair. Then, behaviors of shaming, blaming and judging are avoided. Leaders must take time to listen, acknowledge, provide resources and offer follow-up if an employee appears to be struggling. Education on recognizing a suffering colleague and offering peer support is necessary.
Ideal support is also constructive and protective rather than punitive. Common tactics for providers who are underperforming or disruptive still include the outdated practice of shaming which undermines the employee’s self-esteem. For example, it is a punitive act to withhold a provider’s pay until delinquent charts are completed. Peer support to help overcome perfectionism and procrastination tendencies that have led to the charting backlog takes courage.
There are many immovable forces that drive our leaders to make decisions and enforce rules that may be unpleasant, and response to change is as unique as the employee.
But, in the trauma and aftermath of the pandemic, where there may be fear, anger, and resistance to change, there is also post-traumatic growth. If an employer creates a work refuge that honors the primary human desires for safety, belonging and dignity, there will be a cultural shift toward institutional courage.