Causing harm but doing good: Recognizing and overcoming the burden of necessary evil enactment in healthcare service professions

Introduction: Necessary evils in healthcare service professions

Necessary evils, as defined by the management literature, are actions that cause some form of physical, psychological, or emotional harm to victims but that are enacted for the good of either the victim or society. ¹ While some acts of mandatory harmdoing are less frequent, many are commonly occurring tasks that are a fixed component of healthcare practitioners’ work, such as delivering bad news to patients ² or enacting procedures that are physically painful for recipients, such as the administration of vaccines. A recent study on the difficulties of the work conducted by nurse managers, ³ noted the profound regularity with which these employees had to conduct these acts and the healthcare profession abounds with examples of what practitioners consider to be necessary evils - from patients receiving tube feeding in acute care ⁴ to the use of restraints in mental care settings. ⁵

Though the body of literature on necessary evils is small, it has often focused on behavior conducted in helping or service professions. ⁶ Necessary evils are especially prevalent in healthcare service professions, as these jobs commonly involve interactions with other individuals or clients who are in a vulnerable state – meaning that professionals’ interactions with them frequently create harm in the pursuit of helping these individuals. Even in roles that are not largely client-facing, healthcare workers may be asked to perform acts of harmdoing. These positions often demand that managers make difficult decisions that are for the good of the organization but are harmful to workers or clients (e.g. shift rotations that are beneficial for patients but fatiguing to practitioners). It is important to note that this paper does not distinguish between necessary evils with differing frequencies and the various employee expectations of enactment outcomes dictated based on these frequencies – for example, some professionals may find that they enact harmdoing daily (e.g. surgeons performing surgery) while others engage in such acts less frequently (e.g. hospital administrator announcing layoffs). This paper argues that as job tasks, necessary evils bring with them different demands on workers than other types of tasks (e.g. checking patient charts; giving sponge baths).

Despite the work conducted by ³ in identifying the prevalence and possible ramifications of necessary evils for both enactors and organizations, necessary evils have not been substantively studied within the healthcare and management literature. Although healthcare’s ideal aim is to reach zero harm (as noted recently by the World Health Organization) - with a focus on reducing all avoidable types of harm ⁷ – this paper focuses on those circumstances in which suffering is inescapable. For example, certain physical interventions (e.g. medical procedures) will necessarily result in physical pain for patients. In these cases, the necessary action is inextricably linked with harmdoing. This paper argues that it is essential that the literature examines and addresses the unintended consequences of these acts on both enactors (i.e. employees), their clients, and their organizations. Aside from studies focusing on a single type of isolated organizationally-mandated harm-doing – layoffs,^8–10 researchers know very little about how those who are forced to enact periodic necessary evils are affected by these tasks. This conceptual work examines three questions: First, what is the role of necessary evils in healthcare? Second, what is the impact of enactment on workers, their patients, and their organizations? And lastly, how can organizations mitigate the possible negative outcomes of these acts on healthcare workers? The objectives of this paper are also threefold: exploring necessary evils in the healthcare context, understanding the impact of enactment, and identifying ways to address enactment’s negative effects.

Within the healthcare literature, studies have empirically examined various types of necessary evils individually (e.g.^4,5) but less commonly do they explore different types of acts at the same time. Moreover, such studies often focus on the affective labor involved and less so on the cognitive component (e.g.^11,12). This paper pushes the literature forward by conceptually working on these two gaps, providing avenues for future empirical research.

This paper will next examine the effects of harmdoing on healthcare service professionals in terms of two types of load burdens these acts create for enactors: the emotional load and the cognitive load of harmdoing. It will then explore the effects of harmdoing on stakeholders, in the form of disengagement from patients and disengagement from the worker’s organization. Lastly, three viable pathways to alleviate each of these two burdens (emotional load, cognitive load) will be presented – namely, work rotation, support groups, and a focus on purpose. These ideas can be seen in Figure 1. All central constructs are defined in Table 1, in the Appendix.OPEN IN VIEWER

The effects of necessary evils on healthcare professionals

Earlier studies, such as^13,14 have argued and demonstrated support for the existence of different types of burdens that necessary evil enactment cause in enactors. This paper suggests that an emotion load ¹⁵ is likely to be carried by healthcare employees by virtue of the caring nature of their jobs, which is fundamental to most healthcare professions. This load concerns not only the compassion most professionals experience and display towards patients but also managing or avoiding the spillover effects of the emotional experience of the patient themself. The paper secondly focuses on the enactor’s cognitive load, ¹⁶ which is the mental burden of necessary evil engagement since many healthcare procedures require a complex set of challenging tasks to be completed and I suggest that the burden associated with the nature of most necessary evils (i.e. the harm is clear while benefits may be less obvious and derive at a later time) mean that cognitive processing associated with necessary evils are likely to be higher than with other procedures. It is also critical to note that I suggest that there are various organizational, situational, and individual factors that can affect the harm associated with enactment – e.g. fatigue experienced by enactors, the complexity of the situation, the culture within the organization. Although it is beyond the scope of the current paper to examine the full range of the mechanisms that affect the magnitude and salience of the necessary evil, such mechanisms can influence organizational and enactor outcomes.

Buffering the negative effects of necessary evils through managerial actions

Although it is unlikely that practitioners can fully alleviate the negative cognitive and emotional effects of necessary evil engagement, this paper proposes three facets through which managers and healthcare service organizations can attempt to minimize negative outcomes: allowing for work and/or task rotation; establishing employee support groups; and encouraging employees to focus on the purpose of the act. Allowing for work rotation should mitigate some of the cognitive load suffered by employees; creating support groups will reduce the emotional burden; and that refocusing on the greater good (e.g. the patient’s health, the healthcare organization’s survival) will lessen feelings of patient and organizational disengagement. Each of these three avenues are discussed below.

Discussion and implications for healthcare organizations

This paper has provided novel ways to think about necessary evils and organizationally mandated harm-doing within healthcare professions and organizations. This paper tried to provide healthcare management researchers with insight into how such harm-doing affects not only the organization but also the employees who are tasked with enacting such actions. The current work should also encourage future studies in which different types of necessary evils are comparatively analyzed, giving us a wider range of knowledge on how such behaviors affect both receivers (those being subject to necessary evils, such as patients) and enactors (those enacting the necessary evil, such as social workers). For researchers more broadly, the current model should open up a line of inquiry into how enacting behaviors that hurt others at work (e.g. patients) can affect employees in both the short term and long term. Future research will likely wish to clearly differentiate between stakeholders who may be affected. Moreover, researchers may benefit from distinguishing between mandated and non-mandated harmdoing, and between necessary evils that are potentially part of a job (e.g. announcing pay cuts) versus those that are integral (e.g. conveying bad health news) and their differential effects on commitment. The paper would also help researchers start to consider the spillover effects of necessary evils – i.e. how such requiring such behaviors may affect not only enactors (such as care providers) but the organization, and critical organizational stakeholders (such as clients and patients), as well.

For organizations, learning more about the indirect effects of mandated harm-doing should serve to underscore the importance of proper delegation and oversight of such tasks. Although not feasible in every case, when used appropriately, delegation is an important tool that may be used to alleviate felt burden. Managers would do well to enact certain of the suggested solutions highlighted here that may work to mitigate the unintended negative aftereffects of necessary evil engagement. These solutions, such as fostering support groups, would need to consider both the current workplace culture and the individual needs of employees conducting such work. For policymakers, understanding the dynamic nature of the effects of harm-doing over time is particularly important and should inform regulations for those who perform work that involves necessary evils within healthcare industries. For educational institutions who train individuals in these professions, integrating and addressing the issue of necessary evils in coursework will likely be worthwhile.

There is much room for empirical research, both qualitative and quantitative in design, in this area. Researchers know little about the long-term effects of mandated harm-doing, making longitudinal studies particularly valuable in this realm of inquiry. Do healthcare workers learn to mitigate the psychological effects of harm-doing over time, or are they compounded with repetition? How much of the burnout and/or turnover experienced in these professions can be attributed to necessary evil engagement? What times of professional training interventions can best address the negative repercussions that can arise from such acts? When and how does experiencing the positive effects of harmdoing (e.g. seeing patient recovery) buffer or counterbalance the negative effects of future harmdoing? The boundaries of this paper are that it did not delve into the patient’s perspective and the influence of both patient and providers’ expectations. Those seeking medical help will commonly recognize that interventions will cause some form of pain but be for their betterment. Other types of harmdoing, such as a hospital manager making unwanted scheduling changes, may elicit different expectations from those affected by this act, thus altering the harmdoing experience. Distinguishing between types, regularity, and stakeholder expectations of harmdoing, provide multiple future research venues. Future research should also consider the enactor’s lived experience of which acts have the most impact on practitioners, how they choose to respond to each act, and the magnitude and type of burden associated with each act. For those who are continually adversely affected by harmdoing enactment – e.g. experiencing feelings of guilt or distress – these reactions may signal a lack of fit between oneself and one’s profession, thus demanding further examination. Another fruitful line of inquiry involves examining the spillover effects of harm-doing to personal life. Are those tasked with necessary evils able to divide their actions within their professional lives and personal lives in a way that minimizes harmful crossover in terms of role effects? Are enactors less sensitive or more sensitive to harm-doing outside of their organizational roles after performing role-prescribed harm? Field studies employing an experienced sampling (or diary study) method are likely to be especially useful to address these, and related research questions.

In conclusion, this article suggests that it is critical to acknowledge the hefty cognitive and emotional toll that enacting necessary harm takes on healthcare professionals. Although healthcare workers are trained professionals, armed with the knowledge that their jobs require them to perform harmdoing for the good of the patient and society, it is important to both researchers and managers alike try to better understand how these acts affect workers so that we may best serve to alleviate the resulting burdens.