Before I knackered my knees, I was an ardent fell runner in the north of England (fells are rugged moor-covered hills). I even entered fell races, which could be quite competitive. The fell running community was mostly friendly but included an obsessive minority after personal bests at all costs. One time I was nearing the end of a 10-mile course when I overtook a male runner in a field full of mud. He took umbrage at this, sprinted to catch me up and, as he ran past, knocked me over with his shoulder. I saw him at the finishing line and went over to suggest that this was not the way to treat a competitor. He looked at me covered in mud and said: ‘if you don’t want to get dirty, you shouldn’t be a fell runner.’
It’s like being a health professional. I can accept that there will be mud and rain, and that it’s hard to keep going up that hill. But you don’t expect to be pushed over by someone and then be told it’s your fault for participating in the first place. Blaming an individual for external stressors, for being bullied within the system and for lacking resilience deflect attention from organisational failings.
In addition, the competition for hardship is wearying. The mantra of ‘it was worse in my day’ and the discourse about snowflakes, with the implication that younger people are too sensitive for modern life, is not helpful.
Being a health professional is a challenging occupation, but it can have many rewards. It is an altruistic vocation and, typically, practitioners are well-respected and trusted in society. Many of us are better off financially and in better physical health than our patients. But we are also susceptible to mental health problems, a situation discussed more frequently since the pandemic. When we are not functioning properly, waiting for the day to be over, wanting to hide from the next patient, crying in the toilet or wondering how to put on a cheerful face, patients and colleagues are at risk. In addition, we carry guilt about not coping – this patient has so much more to put up with than I do such as a chronic medical condition, a violent partner, poor housing, and no solutions in sight. If I take time off work, my colleagues have to work harder, and the patients have to wait longer.
Burnout can arise from excessive and prolonged work-related stress that leads to mental, emotional and physical exhaustion. The job becomes overwhelming and its demands unachievable. As yet, burnout is not an official medical diagnosis, rather it is classified as an occupational syndrome by the World Health Organization. The conditions it may cause such as anxiety and depression are, however, clinical diagnoses. Burnout can occur when additional life stresses at home or at work are added to an already challenging role, for example, family breakdown or illness, being passed over for promotion, bullying, money worries, etc. In the pandemic, we also saw lack of proper personal protection equipment against Covid-19, longer hours and fewer staff, more patients dying, and lack of control over working conditions.
Burnout may be stigmatised and seen as a personal problem. In healthcare sometimes we feel the need just to get on with it. If my colleagues can manage, so can I. But how many are pretending to be ok?
Admitting to being stressed or seeking help may be considered a personal weakness. Probably someone, somewhere, will say we lack resilience. Moreover, if we do seek help, then the treatment may also be offered at the personal level – advice to take up yoga and exercise outdoors (preferably amongst trees), to practise mindfulness and to have more rest. No! No, we shout inaudibly, it’s mainly due to our working conditions, the boss and the hierarchy, the need to see patients every ten minutes, the paperwork, the two-year waiting time for patients needing hip replacements, the lack of social work appointments, the failure to be able to solve the world’s problems. We haven’t time to fit in the cure. Sure, it may be possible to take time off and rest, but coming back nothing will have changed, and the worries start building up as the downtime is forgotten.
The quadruple aim is a framework for the delivery of high quality and high value health care. It adds an extra dimension to the triple aim defined in 2008 that has three goals: to enhance the experience of patients, to improve population health, and (particularly pertinent for the United States) to reduce the cost of care. The 2014 additional fourth goal recognises that a healthy workforce is necessary for optimal health care delivery and emphasises team well-being to improve the work life of health providers.
There is an increasing amount of literature focussing on health professional well-being. We know what can help. For example the Grattan Institute in Australia, summarising a review on workplace burnout, lists ‘increased availability of supervisors, protected time to ensure that time off really is time off, and shared scheduling to avoid long stretches of uninterrupted shifts’ as effective strategies in hospitals. It then helpfully reminds us that these improvements can only be made ‘if healthcare workers are available’ and states that governments need to act as well.
In the (long) meantime some organisations are trying their best with staff wellness programs, easier access to psychological support, and enhanced facilities for breaks including nutritious food. It is important that improvements are available for all staff, whatever their profession or role.
The mud is still there, and we will still get dirty. What we shouldn’t have to put up with is being pushed further into the quagmire by being blamed for the situation.
For further reading on resilience see
Hossein Khalili, Dean Lising, Giray Kolcu, Jill Thistlethwaite, John Gilbert, Sylvia Langlois, Barbara Maxwell, Mukadder İnci Başer Kolcu, Kathleen M. MacMillan, Carl Schneider, José Rodrigues Freire Filho, Ghaidaa Najjar, Zaid Al-Hamdan & Andrea Pfeifle (2021) Advancing health care resilience through a systems-based collaborative approach: Lessons learned from COVID-19, Journal of Interprofessional Care, 35:6, 809-812, DOI: 10.1080/13561820.2021.1981265