Organisations are created with a purpose. In order to fulfil that purpose there needs to be forms of control within the organisation over the workforce. This post discusses the significance of shame as a disciplinary force explaining how and why doctors come to feel shame.
Shame is a powerful feeling. The anxiety of feeling inadequate, of getting things wrong, and being seen to be a failure are strong drivers in social interaction. Avoiding shame can drive behaviour and self-presentation. While this can occur on a conscious level, it can also be habitual and, therefore, slip from daily awareness of why we act in the way we do. This applies to patients and doctors as much as it does managers, leaders, civil servants and politicians. There is an ongoing process of shame avoidance that occurs and all levels and interactions. Being shamed only serves to reinforce the need to avoid being shamed in the future.
Feeling shame relates to standards. Yet we are not born knowing a set of standards that we must live up to. Rather, these are created by people in groups, and then applied back to the people within the group. In many cases, these standards provide a loose consensus about the way people should think, feel, and act. In some contexts, however, those with power and influence within a group may come to the view that a greater level of control is necessary over members of the group to generate greater levels of conformity.
All organisations have formal processes for discipline, hierarchies with power, and possibilities for judgement, criticism, and expulsion from the organisation. As doctors come to understand the organisation’s rules, standards, and expectations, they carry these in their minds, resulting in self-surveillance and controlled self-presentation. Doctors may be shamed for non-compliance but feeling shame for a sense of failure is likely to result in it being hidden for fear of further criticism and judgement.
While political and organisational leaders and managers may proclaim that the shaming of anyone is abhorrent, the practice of shaming doctors should not be seen as a form of managerial misbehaviour. Rather such shaming takes place within a wider context that frames such action as justified. Shaming can be strategic and purposeful when someone transgresses organisational rules. Equally, attempts to contain, alleviate, or divert feelings away from shame can also be strategic and purposeful, as managers do not want workers feeling shame for doing things that they are employed to do.
Attempts at regulating shame in others may create the desired effect of evoking or containing shame, but this is not necessarily the case. Everyone carries with them their own set of contexts, personal experiences, and ideas of who they are and want to be. Seeking to regulate someone else’s feelings, especially around ideas of ability, capability, and character, can result in a range of emotions for the target of the regulation. Anger and humiliation are possible feelings that may generate feelings of resistance more than compliance. Even feeling shame may not result in the level of conformity intended. Indeed, people may seek to influence, manipulate, and sabotage efforts to regulate someone else’s feelings, or in some cases simply leave the environment claiming it has toxic effects.
All of this may sound like setting boundaries for shameful behaviour has dark underlying intentions. However, rather than seeing this process as good or bad, it should be seen as simply a social and cultural process that exists that can be heightened within organisations. Being aware of such a process provides opportunities for ethical, humane, and creative practice. Indeed, some behaviours and actions should be seen as shameful. Hurting or harming vulnerable people is widely seen as immoral. The question is where is the line on what is acceptable and not acceptable professional behaviour? Conflict is created when pressures from outside of the profession of medicine impose ideas about practice onto medical organisations and services that are outside of the ideas for good practice within it. It is at such crossroads that we see doctors being shamed for failing to meet administrative tasks, performance targets, or other business processes that have little bearing on the actual quality and effectiveness of their work with people. Aligning the boundaries for shame with professional ideals, practice and research evidence is most likely to gain widespread professional agreement. Ensuring that doctors are not shamed for taking time to understand someone’s problem or trying new things they genuinely believed would help would facilitate innovation and creativity. While ensuring that those who do cross the boundaries of acceptable behaviour are not treated in such a way that it humiliates and demeans them. A humane system is not one without shame. It is one that is shame aware, offers ways of repairing damage, and treats people as human beings, worthy of acceptance, even in the face of failure.
Dr Matthew Gibson