Insights (Essays)

Insights (Essays) March 2013

Empathy: A Foundation for New Conversations

Hugh MacLeod and Wendy Nicklin


Today on the balcony I am joined by Wendy Nicklin, a respected national healthcare leader. We admire the healthcare system for its intelligence and brilliance, yet we wonder: What are the barriers to making best use of this intelligence and brilliance?

The more we know about leadership and change management in healthcare, the more we realize the things we do not know. That being said, we learn a little more each day: from board members and senior management; to front line care providers and support staff to patients, residents and clients served. We know the answers are within their hearts and minds. They provide us with valuable feedback and lessons learned – and we need to hear more and welcome more.

We know the answers to any organizational dilemma can be found within. We also know strength comes from looking for answers within. So again: What are the barriers and challenges to optimize this intelligence, expert knowledge and ideas? One answer emerges from a haunting, familiar voice – that of the critic, the Ghost of Healthcare Despair. 

“You talk of brilliance yet reveal little of it,” says the ghost. “The delivery system has demonstrated an unwillingness to collaborate with local health partners to make the appropriate changes. If you are going to be successful in managing change over the next four to five years, you must learn from your ‘best mistakes.’ If you’re so brilliant, you must show a willingness to carefully and systematically examine the basic assumptions you are holding about the current and future system.”

We believe assumptions are not facts. They arise from the beliefs we hold about our reality and vision. We assume, for example, that we don’t have the answers to our dilemmas. We must challenge that assumption. Belief can be enabling, but it can also cripple. Beliefs must be continuously challenged, tested and renewed.

Risk taking is inherent in healthcare. Considering our “best mistakes” honours this process. We work in a kind of paradox. Many in healthcare actually think and act in isolated silos, as systems under siege, while they believe they are externally collaborating. On the other hand, many governance and managerial leaders see themselves in relationship with local health services delivery systems, regions and territorial/provincial partners in the delivery of care.

We must acknowledge that healthcare leaders both informal and formal want the best for the population they serve. There are many tremendous innovative solutions being applied to improve quality and patient safety. That being said, much of the current structural tension and uncertainty we experience arises from this fundamental dichotomy: to focus internally and find a solution or work as a system? To say it differently: Do we preserve the status quo or become stewards for the emergence of a new phase in the evolution of the system?

How do we, personally, help the system outgrow this paradox? It requires a shift; a shift from leadership by the infighting brilliant strategists towards imaginative and innovative analysts, cooperative teams and collaborative risk takers that enable the healthcare system to evolve in a self-organizing way. That is the foundation for real power and sustainable transformation. The fundamental capacity exercised by effective leaders has two sides to it: to forgive and to make promises. We must also recognize that some results are final and cannot be corrected; that it is not always immediately possible to forgive and deal with those situations. But we are not to slaughter the scapegoat. The promises we make to each other create islands of stability in the chaotic phases of life. Our basic promise is to allow each other to be human and commit ourselves to cleaning up the messes no one could foretell. It is crucial to recognize that moving forward with change is not a criticism of the past but, rather, a recognition of positioning for the challenges of the future.

To be drawn to the work of transformation is to be drawn to the centre of the human condition – the eye of the storm. Here, what is needed most is strength and humility. Strength comes from what can be accomplished as a collective. Humility comes from understanding the right relationship. Both, together, create an awakening. The danger of leaders who are committed to change without in-depth learning is that they often confuse the power of the organization with their own strength. By speaking of the world as it is and what one can and cannot do, the leader helps others find their place.

What tends to occur when only superficial, transitory change occurs – your “quick fix that fails” – and with it, an increase in isolating fragmentation? The follower becomes discouraged and says to him/herself and colleagues: “Here we go again, not another change for change with minimal outcome, just more process work … next, we will hear of another organizational change … the chairs move once again.”

Staff who are suspicious and cynical become absorbed in self-protective practices. They are less likely to take risks, to speak out when it is called for, to question ideas that need examination, to participate during meetings, or to take a chance that a fresh approach might be the answer to a problem. They fear speaking truth to power. Who, after all, is going to expose themselves to risk or commit to an organization that weakens their sense of efficacy or threatens their very existence? Who identifies with a  system that keeps them small?

So, how do you restore trust? This is perhaps the most significant challenge facing the Canadian healthcare sector today. The question facing healthcare leaders is how to create new levels of empathy and responsiveness throughout their organizations and across thousands of patient, resident and client encounters. The authors of The Empathy Engine suggest the following: 

  1. Tap Into the Informal – Are you encouraging people to do the right thing when they see barriers to meeting patient needs? Have you provided them with guidance? What are you learning from today’s workarounds? Are you spending time walking the halls and taking time to listen to employees? Are you demonstrating the empathy you want to see in your organization?
  2. Strengthen the Formal – Are you explicit about the importance of empathy – is it a criterion for hiring, rewards and advancement? Have you identified the groups of current employees who have particularly strong service experience or inclination? Have you a plan to share best practices within your organization?
  3. Harmonize the Informal and Formal –Have you identified pride builders and what sets them apart? Do you share and cultivate those traits across your organization? Do you encourage leaders and employees to tell stories of service to capture and spread? Do you engage in collaboration and experimentation to find ways to keep your employees, including managers, close to the patient experience, so they can work together to innovate based on what they are learning on the front lines?

Many companies have discovered how “empathy” creates a holistic and focused competitive advantage. They sense customer problems and consistently act on them by keeping information and values flowing throughout. This flow of information includes key insights learned by the front line during their interactions with customers. The flow of values is the organizational commitment to empathy and customer service. Healthcare organizations can learn from companies in other industries that have used empathy and pride building efforts to motivate large groups of employees to improve service.

A few years ago, Bell Canada needed to make radical changes to many of its programs and processes to keep up with changes in the industry. As part of their turnaround plan, they looked to distinguish themselves on customer service, but they did not have time for formal programs that would take years to implement. They started by seeking out their pride builders – those managers who were already demonstrating the desired behaviours and encouraging them in their people – and brought them together to share best practices and build on the already existing energy to transform the organization. A series of local performance improvement pilots, driven by the best practices and energy of the pride builders, yielded impressive customer service results: employee commitment, customer satisfaction and sales all increased. Under strong senior leadership, pride building became a “movement” with Bell Canada. In the first three years of the effort, the informal community of pride builders grew from the initial group of 12 to a thriving network of over 1,000 managers. The numbers say it all: 29% increase in customer satisfaction, 10% increase in productivity and 13% increase in pride and motivation.

Tapping existing sources of pride in healthcare organizations can build momentum and energy and dramatically improve how an organization delivers patient services. The greatest challenge in building respectful relationships is to support someone’s struggles and differences, to hear and acknowledge the way they feel and think – even when they are scared or angry – and to listen without judgment and without taking responsibility for each other.

This is true respect – accepting one another for who we are, believing in our inherent worth and capability, allowing each other to be human and make mistakes, while holding each other fully responsible and accountable for our behaviour and our communications.

When we are empathetic, we have the capacity to perceive the subjective experience of another person. We demonstrate empathy when we imagine another person’s feelings, emotions and sensitivities, think about how we might feel in their situation, and then behave in an appropriate way. To be empathetic, it is necessary to be self-aware. When we are self-aware, we are in touch with our own emotions and, therefore, are more able to read others’ feelings. Empathy leads to quality relationships, integrity, trust and good communication.

Next Week’s Guest on the Balcony of Personal Reflection: C. Power in a conversation titled “Asking, Listening, Talking”. 

Click here to see the First Series of Ghost Busting essays.


Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness.

About the Author(s)

Hugh Macleod is CEO Canadian Patient Safety Institute. Wendy Nicklin is President and CEO Accreditation Canada


Carnevale, D. Trusthworthy Government. Internet review. 1997 by F. Thomas
Entel, T., J. Machida. 2008. The Empathy Engine®: Achieving Breakthroughs in Patient Service. Booz & Company Katzenbach Center paper.


Shannon Long wrote:

Posted 2013/09/04 at 07:15 PM EDT

Dynamic: self motivated, dynamic, active and energetic. Does this sound like our health care system? I work in health care, I am a nurse practitioner but my job is actually as a detective, a mediator, a guide, a police officer, an air traffic controller; essentially I am an advocate. I don't think the system today is any thing like 'dynamic'. It is mired in bureaucracy, systems, apathy, and stagnation. We race to adopt the qualities of the business world in terms of economics; we count beds, count days, count procedures and complications. We do not however, adopt the qualities of business that make a strong, dynamic company; these include listening to our employees, engaging with them and the surrounding community, making investments in the organization now for future payback, in essence, striving to be a magnet organization. We are over booked, over worked, under resourced and misunderstood both internally and externally. the system is broken. Despite having fabulous resources at our fingertips, we are stuck in old fashioned thinking influenced by the stakeholders that feel they are the greatest to lose rather than by the true needs of those the system is meant to serve. Rather than innovation, we strive for mediocrity and stale processes. We don't listen to the public, in fact we shut them out because we feel it is all too complex for them to understand. I search for a term that is not laden with themes of historical irrelevance, but patriarchal comes to mind. If we are going to develop a dynamic system then we need to not only listen but ask the questions of those most affected, the public.
To actually build a system that is cohesive, flexible, interconnected, cost-effective, orderly and that values the patient voice, there are a few key ideas. EHealth, a chart that follows and maybe is carried by the patient, adopting innovations not just in technology but in service delivery and not just as dictated by any one group, a medical ombudsman (both the military and the correctional system are better represented than patients) in order to ensure transparency of the systems and the money it consumes, and better patient education so that we can help them understand that in life ultimately no one gets out alive. We cannot prolong life at all costs, we need to focus on what is reasonable, not just what is available. Not only the public but those delivering the care must understand the concept that just because we can does not mean we should. Technology is racing ahead and to expect a Royal Commission to put a hold on advancement while we study the effects of this in order that we can rightfully incorporate the changes in a sane manner is not going to happen. We need to dig in, do the work and start the dialogue.
Wendy Bowles, NP F


Shannon Long wrote:

Posted 2013/09/04 at 07:15 PM EDT

After 37 years as a provider the issues I see when I look back on the joys, sorrows and frustrations of a career in surgery can be summarized in the following. The lack of transparency, the need for public education, control of technology, and the need to eliminate double standards in health care.
The lack of transparency is seen in the absence of real information available to the public to see how our government and middle management are applying health care dollars (read tax payer dollars). Do we really need to send crews of middle managers to hug-a-thon seminars when we continue to place patient beds in the corridors of our hospitals?
The public by and large are not rocket scientists. Their main concerns come to the fore when they or their loved ones are perceived to be receiving inadequate care in the current system. They may or may not be correct in their views but their perceptions are strong and valid to them. Therefore, public education in health care is essential but difficult to deliver. The majority of citizens are undoubtedly more intrigued by a bear sighting in the city on the front page of a national newspaper than homelessness or a cut in service on page two. We have to educate the public in a meaningful way that will excite them. Likely through the medium of digital technology.
As for technology, we cannot afford at our current rate of taxation to keep all of us alive to 100 or more although it is quite clear we are heading in that direction and the public feels free to demand this. We need ethicists, patient advocates, the public and those who control the purse strings debating the issues. Feasibility of providing life extending technologies to 80 and 90 year olds when we fail in many cases to provide the necessary care to others in our society who are just as deserving needs to be a focus. This is a difficult job when we do not have the ability to teach all people medical politics and ethics and no one I know wants to pay more taxes for health care.
Regarding the issue of double standards, for all our acknowledgement of the Canada Health Act, standards are not equal across this country. First, most of us are naive enough to believe that the premium we pay for health care on a provincial level actually covers the cost of delivery of that care and ensures equity. This is of course not the case. For examples. diabetes is becoming increasingly common at all levels of society as our eating habits deteriorate and our girths expand and we spend a great deal more time in a digital life than in promoting healthy life styles. Podiatrists and others play an important role in the prevention of devastating complications of diabetes, such as amputations. Strangely, in some provinces across Canada these services are covered while in others it is "user pay". In short, we can cover the costs of a $150,000 amputation but we cannot cover the $70 it costs for a podiatrist or a $300 pair of diabetic shoes. Many of these patients are seniors with limited resources while others may be unemployed with even fewer resources. Who decides the fairness of this arrangement. Are there any ethics involved with this or is it simply a reflection of bureaucracy at work?
Do I have answers? No. But just a suggestion that a non partisan medical ombudsperson in every province and territory could go a long way to affecting some responsible changes that Canadians need and deserve.
Dr. Peter D. Fry


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