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Designing the New Normal:
Agency in Stressful Times
Brooke Buckley, MD, FACS
In Thinking Fast and Slow, Daniel Kahneman describes a thinking model of the brain. Our slow-thinking is methodical and intentional. It helps us process new scenarios and complex problems. We also have a protective ‘fast’ mechanism that allows us to quickly draw conclusions and process massive amounts of information with relative accuracy. (Kahneman, 2011) Fast thinking, so-called System 1, also finds comfort
in bias, assumptions, and plausible, convenient conclusions.
It is the fast thinking that gets us into trouble as the days of pandemic wear long on our collective conscious.
I remember my program director in my general surgical residency telling us to look at ‘every inch of every patient, every day’. He would go on to say that life necessitates
cutting corners. The clinical practice he instilled in us was that knowing all the corners, by hard fought tenacity and competency, would allow us to know which corners are safe to cut. Thereby we could respond to life’s pressures and make safe decisions for our patients.
System 1 is how our brain helps us cut corners. Every time system 1 sees something that looks like ‘normal’, we recognize patterns and make assumptions. Low Covid census, full staffing in the Operating Room, a restaurant full of maskless neighbors all send signals of recognition and safety. We all want to get ‘back to normal’. A place that our memory smooths to be calm, predictable, and safe. A place that is predictable with less stress.
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As we search for return to normal, we need to be aware of System 1 bias. We must be skeptical of corners we think we know and stay curious about how the pandemic has changed us even in the face of seemingly normal patterns. We can feel, but struggle to define, the uneasiness when, even at
full staffing, and predictable work hours, delivering healthcare feels harder. An article from EPIC Research in June of 2022 called ‘The New Nurse’ is the New Normal shares that the median tenure of nurses
in the Midwest fell by 16.4% from March 2021-2022. (Team A: Johnston Thayer &
Joe Zillmer, 2022). Additionally shifts filled by nurses with less than one-year clinical experience rose by over 50% in the same time. Nursing tenure is one such example where old patterns represent new normal. Experience promotes safety. Newness requires appropriate support and guidance.
In the physician community, we have seen less turn over and greater stability in our workforce despite
retirements and job changes. That said, the deleterious effects of burnout have been well documented for years. Physicians consistently demonstrate a 50% burnout rate. During the pandemic, we have experienced incredible increased stress and disruption. We know these reflect in burnout related measures of workforce strain: conflict, turnover, decreased commitment to work, medical error, disengagement. (Tait D. Shanafelt, 2016).
Herein lies the rub, on average the nursing workforce has fewer years of experience and less service years in a particular institution. Everyone, physicians included, have undergone at least two years of prolonged and unpredictable stress. The interface of the nursing and physician workforces in the face of burnout and inexperience must be examined and carefully handled to maintain patient safety in our ‘new normal’. The corners we used to know (patterns of escalation, bandwidth of house doc support teams, overnight-communication) have potentially fundamentally changed and may no longer be safe corners for cutting.
Trauma-informed literature suggests several opportunities for organizational and clinical leaders to re-establish predictable and safe working environments. Trauma-informed leadership is important because it recognizes what happens
to people. It does not blame the traumatized but seeks to understand the shift in brain chemistry to understand how
Third Quarter 2022