This article was written by one of our contributors; portfolio GP, entrepreneur, healthcare professional, and coach and mentor – Claire Ashley.
In April last year, just a month into the COVID-19 pandemic, it was reported that nearly half of UK doctors were suffering from burnout, depression or anxiety due to pressures at work (1). I counted myself among that number. A Previously enthusiastic GP, resilient and loving my job, at the height of burnout I didn’t recognise the person I had become. With panic attacks, headaches, constant worry, extreme fatigue, total loss of confidence, feeling desperate and despondent, it had taken just 6 months for me to go from never having experienced a mental health problem to being on the verge of a breakdown.I was experiencing several stressors in my life at the time, but the thing that had driven me to this very dark place and ultimately burnout was working under completely unsustainable and overwhelming pressure in my job as a GP.
Burnout occurs after a period of high and sustained stress and was originally used to describe the consequences of severe stress and high ideals in caring professions. First described by Freudenberger in the 1970s, burnout comprises 3 things:
- Emotional exhaustion – the fatigue of caring for too much for too long
- Depersonalisation – depletion of empathy, caring and compassion
- Decreased sense of accomplishment and fulfilment – feeling that nothing you do makes any difference (2)
However, burnout does not necessarily affect those in helping professions, it can affect anyone, including parents (3)
Even prior to the COVID-19 pandemic, NHS staff were already subject to stress factors directly related to the job, such as resource related pressures, long hours, high patient expectations, shift work, and an ever increasingly complex ageing and polymorbid patient population. During COVID-19 the work has become even more intense, with exposure to a large volume of deeply traumatising work in conjunction with difficult and often overnight enforced changes to working practices. Doctors, in particular, often share the same personality traits that increase the risk of us developing burnout, such as perfectionism, fear of failure, and imposter syndrome (4) . The high performing and toxic work culture in medicine also makes seeking help difficult to seek help when struggling.
The term burnout describes a state of apathy after being subject to chronic stress, but before burnout is reached NHS staff might experience symptoms related to moral injury or compassion fatigue. Originally described in war veterans, moral injury is perpetrating, failing to prevent, bearing witness to or learning about acts that transgress deeply held moral beliefs and expectation (5). In healthcare, moral injury is the consequence of being unable to provide high quality care for our patients, despite our deepest and best intentions, and due to factors that we cannot control. It describes the concept of being put in situations with unsustainable pressure, inadequate resources, a sense of wanting to do the “right thing” and not being able to. Work has shown that failing to consistently meet the needs of patients has a profound impact on doctor wellbeing where doctors end up being caught between the principles of the Hippocratic oath and the reality of dealing with a large volume of complex patients at their most vulnerable with little resource (6). Routinely experiencing this is painful, perhaps once or twice you could recover, but these incessant, routine betrayals of patient care and trust ends up becoming death by 1000 cuts. When repeated on a daily basis, they become a moral injury.
Compassion fatigue also factors into the experience of burnout. This is described as a deep physical, emotional and spiritual exhaustion accompanied by acute emotional pain. It is essentially trauma-by-proxy, and happens when the medical professional takes on the stress and trauma of the things that are happening to their patients. It leaves the person affected in a state of physical and mental exhaustion, which in turn can impact on standards of patient care, relationships with colleagues, or lead to more serious mental health problems such as PTSD, anxiety or depression (7). Whereas healthcare professionals with burnout adapt to their exhaustion by becoming less empathetic and more withdrawn, compassion fatigued doctors continue to give themselves fully to their patients, and find it difficult to maintain a healthy balance of empathy and objectivity. To compensate, many doctors work harder and try to take on too much simultaneously. In doing so, there is less time for things that would sustain or recover the doctor from their distress, such as regular exercise or interests outside medicine.
It is impossible to talk about tackling burnout in healthcare professionals without addressing the root cause of the problem, which are the systemic issues that precipitate it. Whilst COVID numbers are currently falling in the UK at the time of writing, sadly, the problem of work related stress in the NHS does not appear to be getting any better. The recently published results of the NHS Staff survey, which had nearly 600,000 responses, revealed that 44% of NHS staff have reported feeling unwell as a result of work related stress in the last 12 months (8). The evidence shows us that there are 2 key factors which help with resilience and recovery, and those are job autonomy (9) and socialising with colleagues/peer support (10). When neither of these things are achievable, whilst there are things that the individual can do to help their recovery, ultimately their recovery will be hindered by not being able to do anything about the stress that caused their symptoms in the first place. As a result, other work on the evidence for burnout management and resilience in healthcare professionals is conflicting, and largely shows that interventions which focus solely on the individual at best do not work, and at worse may in fact make things worse (10).
Early intervention
As with all medical problems, prevention and early intervention is far easier than reactive management. However, if you recognise the symptoms in yourself then the first thing that is essential to do is to seek professional help (from your GP, a mental health organisation) and to consider taking time off work to allow your recovery to start.
Reflection
One of the issues I experienced with my burnout was that I had neither the knowledge nor the skills to recognise or manage it. One of the ways to recognise escalating stress levels is to practice regular journaling and to reflect on your stress levels and your feelings. Over time you will be able to recognise if your stress is starting to affect your mood, your function and/or your performance at work. Checking in with colleagues regularly is another helpful prompt to reflect on your stress levels and how you are coping.
Recovery at home
At home, recovery first needs to focus on your basic physical, mental and emotional needs. That is likely to include physical activity, eating regularly, meditations, prioritising sleep and the practice of gratitude. Get rid of anything or anyone that does not serve you – that might include being on social media, or thinking about which people in your life are not aiding your recovery. You cannot recover from burnout if the things you need to do to recover are impeded, intentionally or not, at home.
Self care at work
At work, practicing self care will be a protective factor in preventing burnout. Self care at work is about taking breaks, taking your annual leave, saying no to work that you cannot safely manage, learning to delegate effectively, and seeking out peer (and senior) support. It might mean making changes to how you work, and considering alternative ways of working that might include less than full time working, portfolio career working, time out or seeking career guidance. It might even ultimately mean leaving the job that caused the burnout.
As for me, it took an extended period of time, a lot of personal reflection and self development, and ultimately leaving my job to recover from burnout.I am now doing much better, and am passionate about protecting and improving the mental health of NHS staff. The impact of stress, moral injury, compassion fatigue and burnout is now becoming a real issue for healthcare professionals following COVID-19, and the figures quoted by the NHS Staff Survey and BMA about the current state NHS staff mental wellbeing are deeply worrying. These results reveal the depths to which a year of working through 3 lockdowns with very limited resources, new ways of working, and increased patient demand has affected the mental health of our dedicated NHS workforce. NHS staff are exhausted and the danger is that these staff will either need time out for sick leave, cut down their hours, or consider leaving the profession altogether at a time when we need as many NHS staff working well to help provide excellent patient care.
It certainly does feel that there is increased awareness and acceptance of burnout and mental health problems in general, and a number of NHS trusts are now moving to provide better mental health support for their staff. However the fact remains that if you put a canary in a toxic environment and it dies, you cannot blame the canary, neither can you expect it to modify its behaviour or coping strategies when the environment it is in is suffocating them. The same is true of burnout. We still have an awful lot of work to do.
References
(1) BMA, 2020, available online https://www.bma.org.uk/bma-media-centre/almost-half-of-uk-doctors-suffering-from-burnout-depression-or-anxiety-bma-survey-reveals
(2) Freudenberger HJ. The staff burn-out syndrome in alternative institutions. Psychother Theory Res Pract. 1975;12(1):73–82
(3) Mikolajczak M, Gross JJ, Roskam I. Parental Burnout: What Is It, and Why Does It Matter? Clinical Psychological Science. 2019;7(6):1319-1329. doi:10.1177/2167702619858430
(4) Gottlieb M, Chung A, Battaglioli N, Sebok-Syer SS, Kalantari A. Impostor syndrome among physicians and physicians in training: A scoping review. Med Educ. 2020 Feb;54(2):116-124. doi: 10.1111/medu.13956. Epub 2019 Nov 6. PMID: 31692028
(5) Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. Moral injury and moral repair in war Veterans: A preliminary model and intervention strategy. Clinical Psychology Review. 2009. 29(8), 695-706. http://doi.org/10.1016/j.cpr.2009.07.003
(6) Dean W, Talbot S, Dean A. Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract. 2019 Sep;36(9):400-402. Erratum in: Fed Pract. 2019 Oct;36(10):447. PMID: 31571807; PMCID: PMC6752815.
(7) Figley, C. R. (1995). Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. NY: Brunner/Mazel.
(8) NHS Staff Survey, 2020, available online https://www.nhsstaffsurveys.com/Caches/Files/ST20%20national%20briefing%20doc.pdf
(9) Khan A, Teoh KR, Islam S, et al Psychosocial work characteristics, burnout, psychological morbidity symptoms and early retirement intentions: a cross-sectional study of NHS consultants in the UK BMJ Open 2018;8:e018720. doi: 10.1136/bmjopen-2017-018720
(10) McKinley, N., Karayanis, P. N., Convie, L., Clarke, M., Kirk, S. J., & Campbell, W. J. (2019). Resilience in medical doctors: a systematic review. Postgraduate Medical Journal, [136135]. https://doi.org/10.1136/postgradmedj-2018-136135
