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An RCPI-led study, which set out to identify priority interventions to prevent and reduce work stress and burnout in hospital doctors, has found that practical, system-focused interventions are of greatest need.
Doctor, how can we help you? Qualitative interview study to identify key interventions to target burnout in hospital doctors was published in BMJ Open on 5 September 2019.
This was the first qualitative study that aimed to identify priority interventions for work stress and burnout by interviewing doctors about their own experiences and their preferences with respect to interventions.
Interviews were scheduled with 16 practising consultants and 16 doctors in training, with a representative mix of gender, specialty and career stage.
Two main areas were explored: experiences of work stress and burnout and suggested interventions for the prevention and reduction of work stress and burnout.
Interviewees regularly described scenarios reflecting a hospital system under strain and sustained pressure to meet unmanageable demand. Human Resources practices, which force sick doctors to secure their own cover, were described as being inadequate and unethical.
The intervention identified by doctors as the highest priority was a review of staffing levels and cover arrangements locally, with the goal of facilitating for all doctors the allocation of statutory leave and ensuring full cover during statutory leave.
Listening to doctors themselves, their experiences of work stress and burnout, and their proposed solutions was a valuable exercise. This study informs the selection of interventions to prevent and reduce work stress and burnout.
Gillian WalshPrincipal Investigator, Doctor, how can we help you? Qualitative interview study to identify key interventions to target burnout in hospital doctors
Over half of practising physicians report at least one symptom of burnout and this number is growing. As well as diminished quality of care, prolonged exposure to burnout can lead to depression and in some cases have devastating consequences for physicians. A doctor is now twice as likely to take his or her own life as a member of the general population.
While research into prevalence, causes and consequences of burnout in doctors has dominated the literature over the past two decades, more recent calls to shift focus to intervention have yielded a number of systematic reviews of interventions to prevent and reduce work stress and burnout in the past three years. Overall, there remains a lack of clarity around which types of interventions are the most effective.
By inteviewing doctors about their own experiences, we now have evidence that challenges with basic entitlements, such as accessing statutory leave and being adequately covered when on leave, require urgent attention.
Other priority interventions identified by this study were a broadening of the support function provided by clinical line managers to their staff, debriefs following difficult cases and adverse events, positive cultural change within the medical community and genuine support for self-care in the workplace, particularly at career transitions and life pressure points.
The overwhelming emphasis on issues of staffing, cover and leave in our study is in line with other studies and not surprising, given the current doctor shortage and growing patient population in Ireland.
We both had to make up all of the calls we had missed during our two months off. So, then we were punished… if you can't have one of the most stressful life events and take a bit of time off if you have depression, what can you actually take time off for without being penalised?Male trainee ophthalmologist interviewed for this study
During the interviews, interviewees were asked to describe any work stress-related ill health experienced. 20 out of the 32 doctors interviewed experienced chronic stress.
Interviewees described a culture in which performance is valued above wellness, in which doctors who struggle to cope are perceived as weak and in which doctors continue to work when physically and mentally ill.
Interviewees’ stories indicate that this culture, while never formally endorsed, begins in the performance-focused, competitive environment of medical school and is reinforced by senior doctors and group dynamics in clinical practice.
Health promotion interventions, which educate doctors at all career stages on the likelihood and risks of work stress and burnout, normalise their occurrence and provide information on pathways to care, were identified as priority interventions. Encouraging and supporting recovered doctors to speak out publicly as part of educational programmes and informally among their peer group were identified as potentially highly effective in breaking the culture of stigma.
Some interviewees described a lack of self-awareness in themselves and in some of their colleagues regarding the impact of work stress and burnout on their health and cited this as a reason they would not seek help. Other reasons included fear of professional consequences, feeling too busy and fear of being perceived as weak. Many described continuing to work to the point where their health problems became very advanced and serious.
This isn’t something specific to a small group of people who just can’t hack it. This is something that is likely to be a challenge for most doctors at some stage in their career… it’s seen as a problem of the doctor rather than a kind of sensible reaction to a non-sensible situation… why don’t we talk about that?Female consultant psychiatrist interviewed for this study
This study found that doctors in supervisory roles are not adequately trained and do not have enough time to fulfil the people management functions of a line management role.
Interviewees described a need to be supported by the hospital throughout their recovery process, along with a need for line managers and occupational health to be aligned and for occupational health recommendations to be adhered to.
Following recovery, though expressing a clear preference for a phased return to work, most participants in the study described experiences of returning to work back at full commitment or with a planned, phased reintroduction, which was not fully observed and with no follow-up. In cases where follow-up meetings were held, the emphasis was often on increasing workload rather than facilitating continued recovery.
Interviewees’ stories of help seeking, recovery and return to work highlighted a management void for doctors, which leaves a considerable gap in what would be normal support structures for other employees. A review of the skill requirements of clinician line managers, which would incorporate line management skills, is needed. In relation to the specific needs of the sick doctor, a training intervention to educate supervising doctors on how to support sick doctors through the process of seeking help and rehabilitation was identified as a priority, tertiary-level intervention.
Although most interviewees highlighted the benefits of venting and sharing day-to-day problems and clinical cases with colleagues, a distinct lack of psychological support for difficult cases and adverse events was described.
Among the potential interventions to meet this need is the introduction of regular debriefing, particularly following difficult cases, adverse events along with psychological support for associated legal processes. Debriefs for everyday challenges and difficult cases should be conducted by a senior team member and should cover psychological impact, as well as clinical learning points.
This study found that doctors who supervise other doctors should be trained in debriefing.
I know for a fact no way would any of the medical staff have any support in that regard (psychological) either, and they are just expected to just work through it and just deal with death after death without any supports.Male consultant in emergency medicine interviewed for this study
Burnout has been associated with increased physician attrition, and as more burnt-out physicians reduce their hours, migrate and seek early retirement, those who stay are left under greater strain. However, while staff shortages are a problem for all hospitals, our study identified better staffing and leave practices in some hospitals over others, resulting in less stress for doctors in training who rotate through those hospitals.
Hospital doctors are feeling the effects of greater demand and fewer resources. What they most urgently need is adequate staffing levels, access to statutory leave and adequate cover when on leave.
It is a recommendation of this study that healthcare organisations not only intensify their focus on recruitment and retention but also review and optimise current practices around cover and leave as the highest priority.
Read the full article on BMJ Open: bmjopen.bmj.com/content/9/9/e030209