WRITER Andrew Christiansen

Time is a well-researched topic in physics and philosophy but less so from an ethical perspective.1 As conscious human beings, we are continually thinking about time. How to best spend the time we have and what constitutes a life well-lived are issues debated philosophically, ethically, and spiritually. In an increasingly capitalistic and social media driven society we are surrounded by the idea that accumulating wealth as fast as we can will lead to a more fulfilled and happier life. Providers of healthcare, however, have a primary duty to preserve their patients’ health and wellbeing, which may often be at odds with motives of profit. Having sufficient time for their required duties is integral to the success of the healthcare process, while cutting corners can lead to significant deleterious health consequences.

Important decisions made in the many fields of healthcare are, unfortunately, all too often based on time constraints. The relatively novel field of temporal bioethics can be described as the exploration of the positive and negative effects on health when decisions are made in relation to time available or time allotted. Perhaps the most evident temporal bioethical deliberation is that of life expectancy.2 Other common issues include treatment times, waiting periods, and consultation times.

This article looks at ethics and the constraints of time in an eye health context from the view of patients, practitioners, and management.

THE PATIENT’S PERSPECTIVE

When a person becomes a patient of an eye care professional (ECP) they place a certain level of trust in the practitioner, which includes that they will perform their duties to the best of their abilities within that designated time frame. If that patient repeatedly visits that same practice or practitioner, then they should expect continued high levels of professional service.

Temporally, patients expect to be seen on time or close to their scheduled appointment. They also expect sufficient time during their appointment to ensure their ocular and vision requirements have been met, with discussion on findings, solutions, and advice. Should the ECP be running late, good practice suggests informing the next patient of the likely waiting time before they are seen or, sometimes, of the unfortunate need to reschedule. Patients are people who lead busy lives. Any inconveniences caused should be acknowledged by the practitioner or practice. It could be strongly argued that a practice or practitioner that consistently runs late is treating their patients unethically in a temporal sense, as patients usually have better things to do with their finite timelines than sit in a waiting room.

Likewise, patients should endeavour to arrive on time for their appointments so as not to disrupt the daily practice schedule. This can be viewed as both a responsibility to the practitioner and to all the following patients that may subsequently be inconvenienced that day. Most practices have a policy that dictates how late a patient can be, before needing to reschedule.

Another patient responsibility is that of their own moral duty over time to optimise their eye health, particularly if they have received professional advice. This should not be confused with victim-blaming, and does not imply that a ‘care less’ patient should be denied treatment, although there is likely an ethical argument there, too.3 If, for example, a fully-cognisant patient has been directed numerous times on the importance of instilling their glaucoma drops but has failed to do so, then it could be ethically argued that any adverse outcomes are theirs to own. Legally, of course, this may not be the case.

Another issue that has attracted significant research is the effects of differing appointment duration times on patients.4-7Much of this research has been undertaken on patients of general practitioners or in a hospital setting, but it would be reasonable to assume these findings could extrapolate to other healthcare professionals, including ECPs. A systematic review by Wilson and Childs found that longer appointment times were associated with more discussion on health promotion issues, particularly cigarette smoking.6 Patient trust in their practitioner has also been found to positively correlate with longer appointment times and a greater duration of the practitioner-patient relationship over time.5,8 The building of this trust is important as it has been linked with adherence to treatment plans and improved health.8 Longer appointment times may also decrease risks of malpractice litigation.9

THE PRACTITIONER’S PERSPECTIVE

From a practitioner’s perspective, time constraints can be quite stressful. ECPs who see large numbers of patients per day could be expected, on average, to experience more symptoms of stress than peers with lesser patient loads. Levels of experience, administration requirements, work culture, and patient demographics are also likely to impact levels of practitioner stress. External personal factors and mental resilience also play a role.

The term ‘time stress’ refers to the difference in time between what a practitioner thinks they need for a consultation and what they are 1Aactually allocated.9 Konrad et al.’s study of physicians from Germany, the United Kingdom, and the United States found that they all reported time stress values of between two to 5.5 minutes.9

The time stress of Australian ECPs has not been formally researched, however a recent workforce survey of 505 Australian optometrists revealed that most of them were not formally allocated time for administrative tasks.10 This could either suggest that consultation times were too short to complete such tasks, or simply that there were too many consults per day. Either way, this will contribute to practitioner stress and dissatisfaction. Dugdale et al.’s study on physicians found that levels of practitioner satisfaction were linked with the amount of time they had to do their work.7 Further to this, physician satisfaction contributes to patient satisfaction.7

Time can also be viewed as a subjective concept. There are 24 hours in a day, but how people manage their time – or indeed their perceptions of how quickly time passes – may differ markedly. The ‘acceleration of time’ relates to the impression that time is passing more quickly than it actually is.11 For example, a person experiencing acceleration of time may perceive that they only have 20 minutes to complete a task when in reality they have 30 minutes.12 Factors influencing acceleration include increased levels of work intensity, greater task workloads, and time pressures.11,12

Ethically, this can lead to a degradation of the ethics-of-care approach, whereby healthcare professionals may be tempted to prioritise economic objectives over their professional duties.11 Experiencing acceleration of the pace of work can drive unethical decision making, which in turn can lead to deleterious effects on workers’ wellbeing.11

Aside from performing thorough ocular examinations in the clinic, ECPs also have emotional expectations associated with their work; they listen and empathise with their patients – this also takes up time. Emotional dissonance can occur if they are continuously compelled to manage these emotions in ways that they do not truly feel, for example faking empathy.11 This discrepancy between required and felt emotions is a major factor in stress and emotional exhaustion.11

Is it ethical, therefore, for employers and managers to push clinicians to increase speed to meet financial objectives when there are known negative effects on both the patient and the practitioner? Wouldn’t a happier practitioner lead to a more positive overall result for a practice, including financially?

THE MANAGEMENT PERSPECTIVE

Practice management and clinical supervisory teams exist for leadership, education, task delegation, and to report to the employer(s) on the health and profitability of the business.

Like practitioners, managers are under time pressures too. But managerial temporal concerns are distinct in that they often require more forward-thinking and planning for multiple business decisions involving multiple employees (or practitioners). One obvious concern is how best to optimise the time spent by employees while at work to attain the most profitable outcome for the practice. Many managerial structures, particularly in optometry, use key performance indicators (KPIs) to set readily quantifiable goals for employees, which may take the form of sales targets, numbers of patients seen, Medicare item numbers used, or cash consults billed. Practitioner ‘performance’ may be evaluated daily, weekly and/or monthly. The success or otherwise of these performances will reflect on the manager, so the managerial concerns regarding when KPIs are attained become an optometrist’s concern regarding the profitability or otherwise of the quantity and quality of their time spent consulting.

As mentioned before, happier employees tend to be more productive, but it is not as simple as that when seen through managerial eyes. Happy optometrists are good, but if they’re not achieving KPIs within the timeline assigned by management, then something may have to change. Managers and supervisors have KPIs too, and while undoubtedly there are many healthcare workers in such roles that are able to juggle their tasks in an ethically commendable way, equally perhaps, there would be many who do not.

Managers experiencing time stressors are more likely to pass these stressors down the hierarchical structure to practitioners, not up to higher management or employers. A manager or supervisor who acts with integrity, respect, and professionalism will try to navigate a path to alleviate these stressors through communication and negotiation with the business employers and the practitioner employees, aiming for harmonious, respectful, and productive outcomes.

However, a Chinese study on workplace supervisors’ behaviour found that when faced with time pressures, supervisors were more likely to have their ‘moral awareness’ impaired, enhancing the likelihood of engaging in abusive supervisory behaviours.13 Such behaviours included any displays of nonphysical mistreatment toward subordinates that violated standards of virtue and posed threats to the ethical workplace.13 Further, the study found that some supervisors may engage in such behaviour because they fail to recognise that their actions are harmful or unethical in the first place.13 Zhang and Jia state that “time pressure draws supervisors’ attention to the features of the environment that are most relevant to task completion, while reducing their awareness of the moral content of the situation”.13

According to Zhang and Jia, within the Chinese cultural context of this study, subordinates may be inclined to be more tolerant of such abusive behaviour than employees in Western societies, and less likely to report it to researchers. The results of such a study in a Western context may reveal a greater number of reported abusive behaviours than those in their Chinese study.13

Evidently, this is rather concerning and should be an impetus for research into the experiences of employees in Australian eye health practices.

SUGGESTIONS

There are no simple solutions; time is finite and there are constant pressures internally and externally on businesses to remain viable and profitable in a competitive environment. Suggestions to potentially enhance practitioner satisfaction levels and practice culture include the addition of more interview questions regarding moral awareness for managerial or supervisor candidates, and increasing practitioners’ control over their appointment schedules.7,13

CONCLUSION

Ethical concerns surrounding the constraints of time are not unique to Australian eye health – they are common to every healthcare profession and likely every occupation. It is how that time is utilised and allocated that aids in defining a profession. For each ECP this will be an individual journey, influenced by many external factors, but collectively we need to remain cognisant of looking after ourselves, how the public view our profession, and how we want it to evolve.

Andrew R Christiansen BAppScOpt MPhil MHSc PGCertOcTher is an experienced optometrist and owner of the Optical Superstore in Bundaberg, Queensland. He is a PhD candidate in Ethics and Optometry at the Queensland University of Technology.

Mr Christiansen is a Board Director and the Ethics Committee Chair of Optometry Queensland and Northern Territory (OQNT). The views expressed in this article are his own, and do not necessarily reflect those of OQNT.

References available at mivision.com.au.