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

Abstract

Necessary evils – defined as acts that cause physical, psychological, or emotional harm to victims but are for the greater good of either the victim or society - are an everyday occurrence in the healthcare industry across the globe and across healthcare service professions. Healthcare professionals are tasked with behaviors that result in pain and suffering (e.g. nurses providing shots to patients; oncologists communicating cancer diagnoses) for the betterment of their patients and stakeholders. Although these behaviors are professionally mandated, they can also be cognitively and psychologically taxing for enactors. The current conceptual paper explores the undesired effects of performing necessary evils and proposes various actions through which healthcare organizations can reduce the negative repercussions of necessary evil enactment on healthcare service professionals.

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.

Figure 1.

Effects of necessary evil engagement and possible mitigating actions.

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.

Weight of emotional load

Each individual deals differently with having to perform tasks that require interpersonal sensitivity. Certain individuals become overwhelmed with compassion for recipients becoming engulfed with emotions such as guilt and sympathy, ¹⁷ making it increasingly difficult for them to perform the needed task. Compassion fatigue – defined as the “traumatization of helpers through their efforts at helping others” ¹⁸ - is a common experience suffered by healthcare professionals. ¹⁸ On the other hand, some individuals focus on creating a buffer from their negative feelings and thus strive to avoid the interpersonal task or minimize the time spent performing the task. ¹³ Whether acting because an employee feels too much for the recipient or wanting to side-step the task in whole, the same negative outcome may result. For example, a doctor may feel so uncomfortable communicating bad test results that they rush patients through the prognosis discussion process. This outcome may protect the necessary evil enactor from suffering the full weight of the emotional load but provides little benefit to those on the receiving end, such as patients or families.

Weight of cognitive load

In addition to the weight of the emotional load carried by workers, there is likely to also exist a cognitive load caused by mandated harmdoing enactment. ¹¹ Given that these tasks cause some form of pain to another individual, the perceived salience of the task is likely to be enhanced. ¹³ For example, when a practitioner knows that drawing blood will cause physical pain to a child, that individual is likely to want to ensure that the job is performed quickly and properly the first time so that it does not have to be repeated and the child does not have to suffer due to our own error. In contrast to tasks that involve causing no or less harm to another party, such as helping an elderly patient get dressed, concerns around poor performance – and the anxiety surrounding poor performance of such a task – are less significant. In this way, the cognitive load may be higher for necessary evils than for similarly difficult tasks that do not involve harming others. Relatedly, the level of cognitive load felt for the necessary evil is likely to affect the cognitive load felt by the enactor. ¹⁹ For example, an oncologist may deliver news of lung cancer to two patients – one who has been a lifelong smoker and one who has never smoked. In the former case, the load may be lightened because the oncologist feels less cognitively burdened for the task as part of the burden shifts to the patient and their choice of lifestyle which increased the risk of cancer.

The effects of necessary evils on healthcare organizations and organizational stakeholders

In their 2008 qualitative study, ¹ researchers developed grounded theory about how individuals respond to necessary evil engagement. Given that the experience of harm-doing can be both emotionally and cognitively intense, ¹² research has shown that enactors generally respond to the experience by disengaging. ²⁰ Disengagement protects enactors both cognitively and emotionally, as it allows for distancing between themselves and the harmdoing act. The current piece proposes that enactors will choose to disengage from two entities most closely associated with the source of the burden (i.e. the task itself) – the victim of harmdoing (e.g. the healthcare provider’s patient) or the entity that mandates the harmdoing (e.g. the provider’s organization).

Disengagement from patients

Those who work in professions that cause harm develop cognitive constructions that allow them to carry out their work. ²¹ Researchers ⁴ found that individuals tasked with harm-doing frequently dealt with the task by disengaging with the action and their victims. For example, pharmacists have been found to be more likely to disengage from patients who display behaviors leading to their disease condition. ²² Although this behavior is often a necessary means through which individuals limit the cognitive load that has come to bear on them through harm-doing engagement, it can also result in creating unwanted distancing between both parties. Given the relational nature ²³ of many caregiving relationships, this is of particular concern in the field of healthcare. Employees who engage in mandated harm-doing are then taxed with not only managing the emotional weight of their own feelings about their required work but also ensuring that these feelings do not transfer into their feelings about patients. Healthcare providers must find the delicate balance between engaging with their patients to provide the best possible care while still developing their own emotional buffer to alleviate the stressful artifacts of conducting necessary evils in caring work.

Disengagement from the organization

Disengagement from one’s workplace has long been viewed in the literature as a lack of organizational commitment. ²⁴ The management literature on organizational commitment has identified three types of commitment: affective, continuance, and normative commitment. ²⁵ Affective commitment examines an employee’s emotional attachment to their organization; continuance commitment is based on the perceived cost of leaving the organization; and normative commitment is the feeling of obligation towards one’s organization. ²⁶ It can be argued that all three types of commitment are likely to suffer from repeated mandated harmdoing. Affective commitment may decrease with repeated necessary evil engagement because of the negative feelings such actions often engender. Continuance commitment may suffer because individuals are more aware of the difficulty of their job tasks and assume that those able to manage such difficult work will be able to easily find work elsewhere (which is evident from employee shortages in such fields). Lastly, workers are likely to feel less obligated to remain in their organizations if they are asked to enact disagreeable tasks routinely, given that job satisfaction has been shown to be a strong determinant of normative commitment. ²⁷ Thus, reduced levels of commitment and increased disengagement from one’s organization – even leading to absenteeism and turnover – may result if harmdoing is not properly managed. Moreover, other types of workplace commitment may also be altered by necessary evil engagement, such as team commitment (i.e. commitment to one’s team) and professional commitment (i.e. commitment one’s profession). Rates of burnout and turnover in the healthcare profession have historically been high (particularly compared to other service-oriented professions) and recent data has shown that these rates continue to increase today. ²⁸ This is a growing concern for healthcare organizations, who wish to retain their employees – particularly as most are both highly trained and in high demand. ²⁹

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.

Work/task rotation

Enabling healthcare workers to rotate their works, or at least enact the types of necessary evils they prefer, should allow a lessening of their cognitive load felt for harmdoing and action salience. This practice has been used regularly in certain industries, such as manufacturing ³⁰ and has also been successfully implemented in service positions. ³¹ Although most healthcare workers are specialists in their fields, workers within the same role in an organization may be able to switch roles or rotate tasks without gaps in caregiving. For example, if a certain nurse practitioner prefers taking care of patient wounds while another prefers administering medication (both of which may be considered necessary evils), providing an option to rotate their work may be beneficial for both parties. Organizations have also found success offering practitioners different contexts in which to rotate their jobs – for example, performing their duties outside of their regular departments. ³² Such solutions will not always be possible and are highly dependent on both organizational flexibility and individual professionals’ capacities, they do provide a possible route to minimize the negative effects of harmdoing on practitioners. Previous studies have shown success in utilizing job rotation strategies. ³³ found that ophthalmic nurses often considered job rotation to be a positive experience that helped with self-development. Similarly, a longitudinal study ³⁰ on three job rotation interventions found the practice successful within a hospital setting across professions, including: physicians, administrative officers and staff, physician secretaries, radiation therapists, and technicians.

Support groups

Many healthcare organizations have already put in place workgroups and meetings or conferences that help their employees deconstruct and address difficult situations arising from their work roles. For example, morbidity and mortality reviews have been put in place at many hospitals to provide collaborative and transparent review process for clinicians to express themselves and examine areas of improvement after patient death. ³⁴ Although necessary evils are not always connected to situations with such extreme possible outcomes, the idea of providing a safe space for employees to express themselves is a valuable response to the burden of mandated harmdoing. Being able to voice one’s feelings should serve to lessen the compassion and emotional load felt by workers and allow workers to know that they are not alone in suffering from this emotional toll. Organizations wishing to improve employee mental health or who fear employee burnout should be particularly open to establishing support groups where employees can share and discuss the emotional burden they are required to bear, ³⁵ while also recognizing that support groups may not be a feasible solution in all circumstances. Such groups work best when they are voluntary and conducted at the employee level, without oversight or involvement from top management or supervisors so that workers feel free to disclose without fear of reprisal. ¹⁴

Focus on purpose

One of the central ways to overcome the cognitive and psychological toll posed by difficult, but required, tasks (such as necessary evils) within one’s profession is to refocus attention on the value of the act to the beneficiary to increase the work’s meaningfulness to employees. ³⁶ In the case of healthcare workers, this beneficiary is most commonly the patient or client (e.g. providing emotionally-taxing therapy) but may also be society as a whole (e.g. providing vaccinations with physically painful side effects). Having managers actively encouraging employees to focus on the greater good achieved by their actions should serve to lessen feelings of isolation and disengagement from both their patients and their workplaces. A large literature has shown that cognitive reframing can have significant impacts on how situations are understood and responded to. ³⁷ If both middle managers and top management teams within healthcare organizations are able to continually remind workers of their role in this process and the greater good that this brought to bear with their engagement in necessary evils, this should provide a psychological buffer to the cognitive load brought on by such tasks. This refocusing also allows workers to move beyond the immediate difficulties experienced to a longer-term, broader view of the positive impact of their work and role within the healthcare system.

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.

Appendix. Table of key constructs

Key construct	Definition
Necessary evil	Actions that cause physical, psychological, or emotional harm to victims but are for the greater good of either the victim or society1,13
Compassion load	The load that performing a task imposes on an individual’s affective system (e.g. 15 )
Cognitive load	The load that performing a task imposes on an individual’s cognitive system 16
Healthcare professionals	Those individuals who are trained in a healthcare profession (e.g.38,39)
Stakeholders	Any group or individual affected by, or can affect, the achievement of an organisation’s objectives 40
Work rotation	An employment activity related to the process of transferring functions, responsibilities, and employee status, to obtain work satisfaction and increase maximum work performance 41
Support groups	Groups that capitalize on the similarity among participants’ stressful experiences... fostering a process of mutual aid 42
Patient disengagement	The process of becoming less engaged with a patient’s care (e.g. depersonalization, withdrawal, avoidance) 43
Workplace disengagement	The process of becoming less engaged with one’s workplace 44
Compassion fatigue	Traumatization of helpers through their efforts at helping others 16

ORCID iD

Meena Andiappan https://orcid.org/0000-0002-4713-508X