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

Better awareness of, and support for, people experiencing shame, particularly in healthcare settings, should be a new international standard for professional practice, say researchers.

Recognising and minimising instances of shame – whether in patients or staff – and developing ‘shame competent’ organisations, could represent a significant opportunity for the health sector to complement other key competencies like trauma-informed practice.

This is the conclusion of ‘The art of medicine: Shame competence: addressing the effects of shame in health care’, a new article published in The Lancet, and authored by academics at the University of Exeter and Duke University in the United States of America.

“Shame has been described as ‘the elephant in the room’ in health care – something infrequently acknowledged but highly active and influential,” says Professor Luna Dolezal, of the Wellcome Centre for Cultures and Environments of Health at Exeter, and co-author. “For more than two decades, since that observation was first made by the physician Frank Davidoff, it remains largely unaddressed in health-care environments; it’s rarely spoken about, rarely acknowledged, and moreover is not taught in health professions training.”

The risk of shame is “infused” in healthcare settings, say the authors, 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 behaviours. So too for health professionals, they add, whose identity and self-esteem can be linked to patient recoveries and outcomes.

“Patients and health professionals alike will do almost anything to avoid shame, making it a powerful driver of behaviour and decision making,” adds Dr William Bynum, in the Department of Family Medicine and Community Health at Duke. “Shame can cause patients to withhold details of symptoms or life circumstances; avoid or withdraw from treatment; conceal illness or diagnoses from family and friends; or discontinue care.

“Similarly, health professionals may be driven to withhold disclosure of medical error or near misses, avoid speaking up when patient safety is compromised, engage in substance use or diversion, or respond with anger, blame, or attempts to shame others, all of which undermine safe, empathic patient care and effective team functioning.”

Shame competence, say the authors, is designed to reduce the potential for shaming, but does not seek to eliminate it entirely, in recognition of its value to a healthy, functioning society.

They set out five pillars on which shame competence is constructed, founded initially on maintaining awareness of shame and an ability to acknowledge the potential for it to occur within daily interactions. Next, they say, comes a recognition of shame, and the way it manifests, its patterns and the behaviours behind it.

The third pillar focuses upon avoidance of inducing shame, either intentionally or inadvertently, and the fourth, of providing proactive support where it occurs. The final pillar concerns the transformation of the organisational culture, embedding the competence in policies, procedures and material conditions.

“Addressing shame to mitigate its destructive potential is a significant challenge in contemporary healthcare settings,” adds Professor Dolezal. “But it’s a challenge that can be met through competence, based upon skills, principles and practices that can be learned and applied in a complementary manner to other approaches like trauma-informed practice and moves to make workplaces psychologically safe.”

The article is based upon research being conducted by The Shame Lab, a research, training, and consultancy organization based between the University of Exeter and Duke University.

‘The art of medicine: Shame competence: addressing the effects of shame in health care’ is published in The Lancet.