Teach the missing psychological skills and reduce burnout in healthcare
Doctors and nurses hold unique positions in our community; they witness the best and the worst of human experience every day at work. They bear witness to our arrival into the world and for many of us, our exit. In between, they are present almost every time our physical wellbeing is seriously threatened and often when our psychology is in distress.
In the best-case scenario doctors and nurses act as our healers, teachers, coaches, champions, and collaborators. We welcome them into our life at our most vulnerable moments and trust them implicitly. We ask them: Can you help me? Can you fix this problem or solve the riddle? We even say… my life depends on you.
In fact, the Ipsos 2019 Global Trust in Professions Survey found that globally doctors are the most trusted profession behind scientists. (In Australia doctors rated number 1).[1]
Of course, sometimes, things don’t go to plan. The riddle is unsolvable, it’s too late, or perhaps the right resources aren’t available. People die, despite the best efforts of doctors and nurses. We remember then that our health professionals are not God after all and that the healthcare system is made up of humans who sometimes fail, despite their best efforts and best intentions.
Somewhere along the way, we seem to have forgotten that doctors and nurses are humans first and healthcare workers second. In recent months there has been a kind of realization about their extraordinary commitment and bravery and we have started referring to them as heroes. A label some doctors and nurses have admonished and resisted; they have enough burden already.
Doctors and nurses confront death, disease, distress, and suffering every day. It should not be a surprise that this takes a toll on them. When we remember that these are in fact people serving other people, made of the same human frailty, it seems obvious that their occupation could be detrimental to their wellbeing.
What is surprising then is the lack of mental health training frontline healthcare workers receive in their workplaces about self care, the vicarious trauma and moral injury, that might be inherent in their work.
Now you might argue that doctors, at least, are not quite the same as the rest of us. They had to be academic high performers at school to be accepted into medicine. It is accepted that many medical students share the trait of perfectionism and as a group, they do show long term persistence and determination, continuing their training for 8-12 years in most cases. Perhaps they are somehow more resilient than most.
And yet, the suicide rate for doctors is higher than any other professional group and higher than the general population rate of suicide in the US and in Australia. In the UK, 430 health professionals died from suicide between 2011-2015, nearly 2 people every week. Some estimate 400 doctors die from suicide in the US every year. Junior doctors and female doctors are most at risk. [2]
The consistency of these shocking numbers suggests a systems problem. This is not just a few outliers who were overwhelmed by the rigorous training of medicine. These people are telling us in the most devastating way they can, that something is not right with the environment they inhabit.
When work demands are chronically high and the individual feels exhausted and overloaded, we describe the person as stressed. For the stressed individual sleep, exercise, nutrition, recovery time, practices such as mindful meditation can help a great deal. However, the chronic repeated cycle of exhausted – recover – exhausted, is not sustainable for most and is hardly describing optimum wellbeing. It is unlikely anyone can deliver on their real potential, living in this cycle. Chronic stress can lead to burnout.
Burnout is classified in the ICD-11 as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:
- Feelings of energy depletion or exhaustion
- Increased mental distance from one’s job or feelings of negativism or cynicism related to one’s job (previously called depersonalization)
- Reduced professional efficacy (personal accomplishment)
The treatment goal for people experiencing burnout is usually to enable them to return to their job and to be successful in their work. Dr. Christine Maslach, the author of the most widely used burnout inventory in healthcare, the Maslach Burnout Inventory (MBI) has been looking at this phenomenon for decades. She points out that these three dimensions of burnout place the individual’s stress experience within a social context. In other words, burnout cannot develop or be treated without attending to the environment.
Burnout is a risk factor for mental illness, but not a medical illness itself. Perhaps some of these doctors who have died from suicide were burned out and their lives could have been spared, if we had understood burnout better and responded more effectively by more radically attending to the health system.
A burned out healthcare worker’s resources are depleted by the context of their work. It is not an individual’s failure, rather a problem that stems from the workplace environment. It is the responsibility of workplace leaders to do something at the top of the cliff, before any more healthcare providers fall off. We all know prevention is better than a cure.
Leaders in health could start by equipping everyone who works in their hospital, clinic or facility with foundational mental health skills. Skills like reflection, cognitive reframing, giving and receiving feedback, compassionate self talk, asking for help, regulating emotions, managing conflict and mindfulness. Skills that psychologists are often teaching healthcare professionals in counseling after too much harm has been done – at the bottom of the cliff. Wouldn’t it be better to equip our healthcare professionals properly before their work harms about half of them?
Health organisations can invest in their workforce earlier than they have done, naming and developing psychological skills from the outset, instead of picking up the pieces after people are already broken.This is critical to delivering the best health outcomes for patients. The research has shown clearly that healthy providers improve patient outcomes and that burned out health professionals, make more errors. Even the most resilient healthcare worker cannot sustain optimum healthy practice if the environment doesn’t support it, if the leaders don’t prioritise it.
If you are a leader in your health organisation, ask yourself – if we prioritised teaching foundational mental health skills to our frontline staff and embedded those skills across the whole workforce, what would happen? Imagine after a few years of committed effort having a workforce who is able to manage their minds, pay attention for longer, be more aware of the impact of their words, regulate their emotions, ask for help in timely ways, be mindful in moments of conflict and challenge, care about each other.
The world is not perfect, there is no recipe that will work the same every time. Still … imagine if your workforce was 20% better at these mental health strategies. What difference would it make to your workplace? To the individuals who work there? To your patients?
The research suggests there would be less medical errors, stress, burnout, conflict and more work satisfaction, wellbeing, psychological safety for providers and happier patients.
Cultural change must be led by those at the top. Healthcare providers – doctors, nurses, paramedics, psychologists – are trained to take care of others. They come to work for others, to serve, and many of them have found meaning and purpose in their work. Not even a pandemic that threatens their own families has stopped them from serving our community. This focus on others creates blind spots in healthcare workers.
Many do not realise they are burning out until it’s too late. Developing skills across the workforce can help people look out for each other, to create the psychological safety that supports people to ask for help when they are challenged instead of relentlessly pushing through, increasing risk to patient safety and to worker wellbeing.
Health care is littered with stories of people being told to toughen up, get over it and you’ll feel better tomorrow. The burden of keep going becomes a personal shame that leads to a negative self-evaluation. The story is not, the system is asking an unreasonable amount of me. The story becomes I am not good enough.
Psychologists can teach other health care professionals important skills for mental health that will help them take better care of themselves. Hospitals, clinics and other healthcare facilities that recognise this and prioritise the development of these skills across their workforce can amplify the impact. Proactively advancing the skills of the healthcare workforce in this way can reduce clinician burnout, improve clinician wellbeing and improve patient outcomes and experience.
Working in healthcare will still be challenging. Doctors, nurses and their colleagues will still be exposed to distress and despair every day. However, they will be better at identifying when they need help and at asking for it. They will have more internal skills to manage their emotions and their minds.
I’m asking you: Can you help our healthcare workers learn the skills they need to stay well? Their lives might depend on it.
[1] Ipsos 2019 2019 Global Trust in Professions Survey. https://www.ipsos.com/en-au/its-fact-scientists-are-most-trusted-people-world
[2] https://www.beyondblue.org.au/docs/default-source/research-project-files/bl1132-report—nmhdmss-full-report_web
https://blogs.bmj.com/bmj/2019/06/13/giles-dawnay-doctor-suicide-how-many-more/
https://www.webmd.com/mental-health/news/20180508/doctors-suicide-rate-highest-of-any-profession
