Researchers recommend the introduction of ‘shame competence’ as a new international standard in healthcare

Better awareness of and support for people who experience shame, especially in healthcare, should be a new international standard for professional practice, researchers say.

Recognizing and minimizing instances of shame – in both patients and staff – and developing ‘shame-competent’ organizations could represent an important opportunity for healthcare to complement other key competencies, such as trauma-informed practice.

This is the conclusion of “The Art of Medicine: Shame Competence: Addressing the Effects of Shame in Healthcare”, a new article published in The Lancetand written by academics from the University of Exeter and Duke University in the United States of America.

“Shame has been described as ‘the elephant in the room’ in healthcare – something that is rarely acknowledged but very active and influential,” says Professor Luna Dolezal of the Wellcome Center for Cultures and Environments of Health in Exeter, and co-author.

“For more than twenty years, since this observation was first made by physician Frank Davidoff, it has remained largely unaddressed in healthcare; rarely talked about, rarely recognized, and furthermore, not taught in healthcare profession training. “

The risk of shame “pervades” healthcare settings, the authors say, with the intimate nature of clinical encounters making it more likely that patients will feel embarrassed, ashamed or negatively judged because of their bodies and/or behavior. That includes health care workers, they add, whose identity and self-esteem can be tied to patients’ recovery and outcomes.

“Both patients and health care professionals will do almost anything to avoid shame, making shame a powerful driver of behavior and decision-making,” adds Dr. William Bynum of Duke’s department of family medicine and community health. ‘Shame can lead patients to withhold details about symptoms or life circumstances, avoid or withdraw from treatment, hide illness or diagnoses from family and friends, or withdraw from care.

“Similarly, healthcare professionals may be incentivized not to disclose medical errors or near misses, to avoid speaking up when patient safety is compromised, to engage in substance use or distraction, or to respond with anger, guilt, or attempts to shame others, undermine safe, empathetic patient care and effective team functioning.”

Shame competency, the authors say, aims to reduce the likelihood of shame but does not aim to eliminate it completely, in recognition of its value to a healthy, functioning society.

They outline five pillars on which shame competence is constructed, based primarily on maintaining awareness of shame and the ability to recognize the possibility that shame can occur in everyday interactions. Then, they say, comes a recognition of shame, and of the way shame manifests itself, its patterns, and the behavior that lies behind it.

The third pillar focuses on avoiding the generation of shame, whether intentionally or unintentionally, and the fourth pillar focuses on providing proactive support where it occurs. The final pillar concerns the transformation of the organizational culture, whereby competence is anchored in policies, procedures and material conditions.

“Tackling shame to mitigate its destructive potential is a significant challenge in today’s healthcare environment,” adds Professor Dolezal. “But it is a challenge that can be met through competency, based on skills, principles and practices that can be learned and applied in a complementary way with other approaches, such as trauma-informed practices and steps to make workplaces psychologically safe. “

Provided by the University of Exeter