AUTHOR: DR ISHANI RAO
Dr Ishani Rao is an NHS GP and emergency medic. After a close encounter with burnout as a junior doctor, she realised the importance of looking after her own mental and physical health, and that of other healthcare professionals.
There are several current buzzwords as we recognise the importance of addressing, managing and preventing mental health issues in medical professionals. ‘Mindfulness’, ‘resilience’, and ‘wellbeing’ are all topics that we read articles about, have training in, and get questioned on by our workplace. However, how has this come about? What is the evidence behind this, and how can we utilise these concepts to reduce burnout and stress in ourselves and our team?
Let’s start with an introduction to burnout, and how we can identify symptoms of this. The term is defined by the International Classification of Diseases as ‘a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed’ (1). This term was only added by the World Health Organisation to the 10th revision of the disease manual in 2016. The term was originally coined in the 1970s by a psychologist called Herbert Freudenberger who observed the development of a loss of motivation, emotional instability, and pessimism in mental health workers volunteering at a free clinic for the homeless community and drug offenders in New York City (2). It encompasses a state of physical and emotional exhaustion that may be characterised by multiple non-specific symptoms. These can largely be grouped into emotional symptoms (eg. pessimism, lack of motivation, irritability, helplessness), physical symptoms (eg. pain, headaches, impaired immune system, fatigue, insomnia) and behavioural signs (eg. procrastination, isolation, substance misuse, reduced performance.) It is important to consider the interlink between the mind and the body here. We must also be aware that symptoms may manifest differently in each individual. It must be emphasised that anyone experiencing the aforementioned symptoms should be reviewed by a medical professional to ensure appropriate investigation and consideration of differentials before a diagnosis of burnout is given.
It has been consistently recognised that medical professionals are disproportionately affected by burnout, with figures suggesting that around 60% of physicians have suffered from occupational fatigue (3). At present there is a lot of conflicting evidence about whether certain specialities are affected, however when compared to other professions the increase in medical professionals is recurrent. A number of questionnaires and research methods have been used, most notably the Maslach Burnout Inventory which assesses emotional exhaustion, depersonalisation, and reduced accomplishment; the three constituents of burnout syndrome (4.) This compares to a recent estimate of 40% of the general population surveyed by the workplace consortium Future Forum (5). Contributing factors to this for the medical profession include heavy workload, variable and unsocial working hours, potential to make life-threatening errors, threat of litigation, physical and mental fatigue, and witnessing traumatic events. This has been exacerbated by the additional stressors of the COVID-19 pandemic, and recent NHS industrial action which, at the time of writing, has not been resolved.
As awareness of burnout increases, we must remember that external factors should be addressed, as well as organisational focus on our own internal resilience and mindset. Literature reviews have consistently suggested that occupational factors, rather than intrinsic personality traits or social circumstances, are the main determinant of job satisfaction and burnout rates . We must consider whether employers are doing everything that they can to ensure the welfare of their employees and of the workforce. This not only benefits the mental health of individuals, but also reduces the number of clinical errors made, improves professionalism and judgement, increases patient satisfaction, improves team morale, and even reduces the number of road traffic accidents for healthcare employees . It is stated by the Health and Safety Executive considerations of human factors that ‘poorly designed shift-working arrangements and long working hours that do not balance the demands of work with time for rest and recovery can result in fatigue, accidents, injuries and ill health’.
Many non-medical companies have recognised that productivity is proportional to job satisfaction and have implemented free stress-reduction techniques such as gym memberships, counselling services, shorter shift times, alternative therapies such as massages and yoga, and mentoring and monitoring schemes for staff to prevent burnout from occurring in the workplace. Within public organisations, such as the NHS, there exist programs and support services for those who are struggling with occupational challenges. Studies have found that interventions such as communication programs, mentoring schemes, and modified work schedules have been effective at improving morale in healthcare workers. It is worth asking your workplace or your GP if any of these services are available to you: details are likely to be available on your workplace intranet and through your occupational health department. Some charities and organisations offer counselling sessions free of charge to frontline NHS workers. One interventional study showed that regular free aromatherapy sessions reduced rates of anxiety and improved cohesiveness in A&E nurses . Further research needs to be conducted into this topic to identify effective ways that employers can improve employee satisfaction.
There are plenty of individual factors that can be targeted and encouraged in order to reduce burnout rates including effective stress management, time management, and maintaining good health, social support networks and personal care. However, any sub-optimal and unsupported working conditions have the potential to induce acute and chronic mental health issues in employees regardless of the mindset, exercise routine, or characteristics of the individual. Organisations and governing bodies should be encouraged to implement rigorous standards to protect their workforce and retain healthcare workers. At an individual level it is important to communicate with your team, line managers, and occupational health department if you feel as though they could support you better.
In the meantime, we must do our best to look after ourselves and each-other. Self-care can look like many things, and some things that might make one person feel comfortable and relaxed may be torture for others, such as cold water swimming or getting a massage! The list of things that constitute self-care is endless. Physical methods may include activities such as exercise, nutrition, eating enough fruit and vegetables, and getting enough rest. A recent study published in the journal Frontiers of Psychiatry demonstrated that individuals who reported a lack of sleep were more likely to report a recent infection and a worse immune response (9). Emotional forms of self-care can include therapy, stress management and relaxation techniques, and self-releases such as journaling. Spiritual techniques can include mindfulness and meditation. Even spending 5 minutes a day meditating has been shown to improve connectivity in parts of the brain using functional MRI mapping (10). Cultivating social methods such as reaching out to a support system, communicating with friends, and setting boundaries (such as declining extra commitments) can be helpful to prevent burnout and occupational fatigue. We all know that it can be difficult to decline taking on another responsibility: the ‘anti-burnout club’ has a helpful guide called ‘How to say no without guilt – a guide for people pleasers’ (11). Managing work stressors with techniques such as taking regular breaks, staying hydrated, and practising breathing methods during stressful incidents has been proven to alleviate occupational tension. There is conflicting evidence regarding the role of a medical debrief, for example after an unexpected death. Some people may find that discussion and debriefing after a traumatic event at work can be helpful; however some studies find that this can exacerbate mental health issues or PTSD in certain people (10). The website ‘Life in the fast lane’ has an online article about how to manage this appropriately (12).
We are familiar with the term ‘prevention is better than cure’; so why are we leaving burnout to be managed so late? We need to break the stereotype that healthcare professionals are the worst patients. Understanding the symptoms and the best methods of prevention is imperative in addressing the growing burnout epidemic amongst our workforce.
Disclaimer: This article does not act as a substitute for medical advice – please contact a healthcare professional if you need further support.
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- Available online on the 10th revision of the International Statistical Classification of Diseases and Related Health Problems- World Health Organisation Version 2016. https://icd.who.int/browse10/2016/en#/Z73.0
- ‘Staff burn-out’. H Freudenberger. Journal of Social issues, 1974.
- ‘Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic’. T Shanafelt et al. Mayo Clinic Proceedings, 2022.
- ‘Evaluating stress: a book of resources’. Maslach Burnout Inventory, Third edition. C Maslach et al, 1997.
- Future Forum: Mission Impact survery. Available online at: https://impact-mission.org/insights/future-forum/.
- Labour Force Survey. Statistics for Health and Safety Executive. Published online, 2016.
- ‘Human Factors: Fatigue.’ Available online at Health and Safety Executive at https://www.hse.gov.uk/humanfactors/topics/.
- ‘The effect of inhaled essential oils on mental exhaustion and moderate burnout: a small pilot study.’ E Varney, J Buckle. The Journal of Alternative and Complementary Medicine, 2013.
- ‘The association between self-reported sleep problems, infection and antibiotic use in patients in general practice’. I Forthun et al. Frontiers in Psychiatry, 2023.
- Revealing changes in brain functional networks caused by focused-attention meditation using Tucker3 clustering’. T Miyoshi et al. Frontiers in Human Neuroscience, 2020.
- ‘How to say no without guilt- a guide for people pleasers’. Anti-Burnout Club. Available online at https://theantiburnoutclub.com/how-to-say-no-without-guilt-guide/.
- ‘Clinical debriefing’. Life In The Fast Lane. Available online at https://litfl.com/clinical-debriefing/).