Gratitude as a human value in healthcare
By Giskin Day PhD. HVHF adviser.
The inclusion of the requirement to treat patients with kindness in the GMC’s 2024 guidance on standards of good medical practice for doctors provoked fierce debate about whether feelings, like kindness, empathy and compassion, could or should be professional requirements. Critics argue that emotions are private and often instinctive, and that their ‘professionalisation’ is an unwarranted intrusion into individual’s psychological life. A more subtle argument, however, such as the one advanced by GP Ben Hoban, is that kindness is a fundamental human value that needs to be encouraged to flourish in a system that supports kinship, rather than being made an obligation.
What place, if any, do feelings and emotions have as values in healthcare? For the past few years, I have been trying to address that question in relation to the emotion of gratitude. I’ve looked at circumstances in which gratitude enhances or detracts from clinical encounters. I’ve studied hundreds of examples of gratitude in consultations in an effort to understand what makes gratitude valuable in healthcare contexts. The topic turned out to be far more nuanced than I had anticipated, and the outcomes were not as predictable as one might think.
It is difficult to distinguish gratitude as a felt emotion from a politeness routine
Saying ‘thank you’ has multiple purposes – mostly as a conversation management technique. We use ‘thank you’ in various scenarios that have nothing to do with feeling the emotion of gratitude, e.g. to bring stretches of talk to a close, as an automatic response to a situation that demands it, or even to convey sarcasm. When speakers do want to convey the emotion of gratitude, they use a number of techniques to intensify thanking, such as repeating words of thanks, adding qualifiers (‘thank you so much’), or augmenting their words with gestures. But rather than trying to discern whether people are actually feeling gratitude when they say ‘thank you’, it is more useful to think of gratitude as an emotion that is co-constructed in interaction. This framing allows us to approaching healthcare as a site of emotional repertoire – a dynamic performance of socially expressed emotion that helps signal our membership of civil, cooperative society.
Extending opportunities to express gratitude is a significant aspect of caring
Gratitude is a significant and meaningful response to situations of precarity. People like – and arguably need – to say thank you to those from whom they have received help. This is especially valid in the case of healthcare when it is unlikely that the opportunity to ‘return the favour’ will ever be feasible. Whilst healthcare professionals tended to focus on favourable outcomes as being worthy of thanking, patients rarely viewed successful outcomes as a condition for gratitude. Most emphasised ‘caring’ over ‘curing’ – it was the effort made, even if futile, that was prioritised in expressions of gratitude.
But when gratitude takes a more material form it can be awkward. The receiving of gifts by healthcare professionals is regulated by codes of conduct, and of course it is difficult to discern if some gifts are given as bribes for preferential treatment. However, the temptation to reject all gifts as a matter of principle should be resisted. The out-of-hand, often tactless, rejection of gifts from patients can cause real harm to relationships in which trust is key. Rituals around gift-giving are culturally situated and need to be handled delicately to avoid causing offence. However, patients also need to understand that gifts can set up conflicts of interest, and it is not possible for healthcare professionals to accept expensive gifts.
Gratitude can also be complicit in care injustice
Those in power often mistake gratitude as compensation for a lack of accountable, practical, and political action. Gratitude can becomes a placatory measure in a misguided attempt to solicit goodwill where none may be merited. As Christian Sorace has pointed out, gratitude can be the ‘ideology of sovereignty in a crisis’, easily slipping from appreciating people to complacency about systems that fail to support them. An example is how politicians repeatedly expressed gratitude to the NHS during the COVID pandemic, whilst failing to provide adequate resources and safe working conditions. Labelling healthcare workers as ‘heroes’ working on a ‘frontline’ often exacerbated the moral distress felt by many facing unrealistic expectations about what was personally and institutionally achievable. Gratitude to the NHS, often welcome and appreciated, has a flip side: it participates in constructing idealised, optimistic fantasies about the NHS in British life. It is ironic that the NHS is intended to minimise conditions of precarity for those in need of care, but it has itself been careering towards collapse with a concomitant increase in precarity for those who rely on it. The NHS cannot run on goodwill and gratitude. Nonetheless, these remain significant resources for action and reaction in a system in which shared human values and impetuses are foundational.
Is there a good way to ‘do gratitude’?
There is no ideal way to convey or receive gratitude. Indeed, the minute we think of a protocol for gratitude, we yet again take a checklist approach for a value that is only meaningful if it is authentic. What we can do is to think about gratitude as participating in relational care. Patients know that those working in the NHS are under intense pressure. They may show that they care by expressing gratitude. In this way, care becomes reciprocal rather than just one way.
Patients’ gratitude does have a morale-boosting effect, but it cannot compensate for a toxic organisational culture. It is relationships between colleagues that often determine job satisfaction and – as the Civility Saves Lives campaign has shown – have profound impacts on patient safety.
Gratitude is only one element of social relationships that contribute to positive working environments. Human values risk being bureaucratised when added to standards, protocols and checklists, but that it has come to the point where it considered necessary, reminds us that the NHS is not an environment conducive to the flourishing of positive social emotions. In the absence of structural change, though, generosity in giving and receiving gratitude is a powerful ‘microethical’ act.
Giskin’s doctoral thesis on gratitude in healthcare is available from this open-access link