Authors: Charlotte Davies / Editor: Liz Herrieven, Nikki Abela / Codes: CC24, CC6, CC8, SLO12, SLO2, SLO8, SLO9 / Published: 07/09/2021
What is Burnout?
Burnout is a specific term used to describe one aspect of mental health. Much research has been done on the mental health and wellbeing of emergency teams – and it’s well worth having a look at the Mind Reports, and TERN’s tired study. The Practitioner Health Programme, a service for doctors by doctors has also prepared a useful report detailing what sort of patients they’ve been seeing throughout COVID. In March 2020 – April 2021, they saw 169 Emergency Medicine Doctors – in contrast to 1995 GPs, 486 hospitalists, 243 anaesthetists, 222 surgeons, and 159 dentists. 4% of their workload were emergency medicine doctors. A third of presentations cited burnout as a presenting complaint.
The World Health organisation defines burnout as:
- Feelings of energy depletion or exhaustion
- Reduced professional efficacy
- Increased mental distance from job, or negativism or cynicism
(Is this the same as compassion fatigue? It depends which source you read)
in the occupational setting. It is caused by chronic workplace stress, not successfully managed.
Because high-achievers are often so passionate about what they do, they tend to ignore the fact that they’re working exceptionally long hours, taking on exceedingly heavy work loads, and putting enormous pressure on themselves to excel—all of which make them ripe for burnout. Some say burnout only exists in overachievers.
— Dornu Lebari (@dornu_doc) January 13, 2020
There are many burnout risk factors, and I’m sure everyone has done a burnout risk score. They include:
- Feeling like you have little or no control over your work
- Lack of recognition or reward for good work
- Unclear or overly demanding job expectations
- Doing work that’s monotonous or unchallenging
- Working in a chaotic or high-pressure environment
- Taking on too many responsibilities, without enough help from others
Personal Risk Factors
- Working too much, without enough time for socializing or relaxing
- Lack of close, supportive relationships
- Not getting enough sleep
- Perfectionistic tendencies; nothing is ever good enough
- Pessimistic view of yourself and the world
- The need to be in control; reluctance to delegate to others
Listing these risk factors is useful, as if you can identify a risk factor you can mitigate the risk factor. The Maslach burnout score is fantastic as it highlights the protective scores too – many of us work in environments which by their very nature encourage burnout – the emergency department wouldn’t be the emergency department if it was controlled, low pressure, organised. But, the emergency department often negates that by having a close supportive team that provides supportive relationships. Some versions also list job satisfaction like “I reflect on the satisfaction I get from being a doctor”.
Rust – out is a profound sense of demotivation and a sense of routinisation with a lack of creativity and meaningful engagement. This means personal interest and enthusiasm is lost.This can occur when you’re so pressured you get no joy from work, when you can’t do what you want to do, or are forced to do things you don’t want to do.
Am I burnt out?
There are lots of signs of burn out, and you don’t need them all to be considered “burntout”. Broadly:
– Signs of physical and emotional exhaustion – chronic fatigue, insomnia, forgetfulness, lack of concentration, stress symptoms, increased minor illness, altered appetite, anxiety & depression and increased irritability.
– Cynicism and detachment with loss of enjoyment, pessimism, feelings of isolation and detachment, and compassion fatigue
– Ineffectiveness and lack of accomplishment with apathy, increased irritability, lack of productivity
Are my colleagues burnt out?
Recognising the signs in ourselves is difficult, and it’s just as hard in each other. We see Dr X once a month, and think their irritability is just a one off. Dr Y is tired – but isn’t everyone? Dr Z isn’t very effective anymore – but that happens to everyone once in a while.
So how do you recognise burnout? We’d love to hear your suggestions – as if you can’t identify it in yourself or others, you can’t treat it. Keep an eye out for increased sickness rates, increased patient and colleague complaints, and reduced productivity.
Avoiding burnout in your colleagues is vital and is an important team function. Again, as a team you can’t change the chaos and the unpredictability but you can change:
* What you talk about – Sonya Wallbank talks about how a focus on graveyard humour, or individual problems isn’t healthy.
* How you talk about things – civility saves, and compassion is important. If you’re heard laughing at people feeling burnt out, then people approaching burn out won’t feel like mentioning it.
* Regularly talk and ask people where they are on the matrix.
* Working Hours – we all know breaks are important, so support everyone to take theirs. Finishing on time is important – but finishing is finishing, and not just leaving the clinical side of things to go and do some admin. As a team, encourage emails to be only answered in work hours, whatsapp to only be used for emergencies or social contact, and finishing on time.
* Encourage effective appraisals – back in 2015 the EMJ supplement talked about how to use the appraisal to talk about stress. It’s a brilliant guide, and one way to highlight wellbeing in such a way it feels like serious work. They’re certainly really useful questions that I’ve started using in my initial educational supervisor meetings, and have yielded some really relevant and useful information.
Preventing Burnout – Individual
Developing resilience is important, but not the only solution. When pressures are higher than resilience, burnout can result. Resilience is a dynamic process that can be learned through acquiring resources. It is the ability of an individual to bounce forward to wellness after significant emotional and / or physical adversity. Resiliency is an individual inborn trait or characteristic, possibly genetic.
All this means that whilst individuals can do a lot to prevent burnout, they can’t prevent it 100% of the time. Here, we group preventative tips into six key groups.
1. Lifestyle Tips
This is where you need to relax, in whatever way relaxes you. Interests and hobbies that make you happy are essential, as are your friends. They can roughly be split into “doing”, “being”, “becoming” and “belonging” activities, and enable us to be introspective, discover the self, look to the future, and forming relationships. This concept is discussed further by Simon Carley in his podcast about self-actualisation and transcendence.
Is it a hobby or an extension of work? If you lost your GMC number, and it meant you couldn’t do your hobby – it’s work. Bellringing = a hobby. Piano playing = a hobby. Model railway building = a hobby. Cake making = a hobby. Crowd doctoring = different work.
One of my colleagues is doing a distance learning history masters – no relation to medicine what so ever, and stops them doing work work. Being an over achiever, we all respond well to a deadline – a hobby related deadline is useful.
Hobbies could be a physical exercise such as jogging, dance, self hypnosis or meditation, a creative outlet such as painting, writing or poetry reading.
In his book First Things First, Dr. Stephen Covey shares the following story. One day a professor stood in front of his class with a large mason jar and a stack of fist-sized rocks. He carefully placed all of the rocks into the jar until they reached the top and then the professor asked the class, “Is this jar full?” The class said, “Yes.” The professor then reached under the table and produced a bucket of gravel. He poured the gravel into the jar and shook the jar so that the gravel fell into all the spaces between the rocks. He asked the class, “Now is the jar full?” The class had caught on by now and one student piped up and said, “Probably not.” Next, the professor pulled out a bucket of sand from under the table and poured the sand into the jar, filling all the spaces between the gravel. He asked, “Now is the jar full?” The class responded in unison, “No!” Finally the professor pulled out a pitcher of water and poured the water into the mason jar. The professor then looked at the class and asked, “What was the point of this illustration?” One eager student raised his hand and said, “The point is, no matter how full your schedule is, if you try really hard you can always squeeze more stuff in.” “No,” the professor responded, “That’s not the point. The point is that if you don’t put the big rocks in first, you’ll never get them in at all.”
2. Physical Health
3. Give yourself a Break
Give yourself a mental break – turn off the tech, don’t sweat the small stuff, outsource as much as possible (get a cleaner, use ready meals), be positive and look for the silver lining, use humour, give things lack of permanence “my boss didn’t like that piece of work” is better than “my boss never likes my work”.
⭐️ get better at switching it off
⭐️ switch on calm + clarity
⭐️ making mistakes is human
⭐️ self-criticism should be quiet
— Kat Priddis (@kls_kat) August 17, 2021
If there are any stressors, remove them, change your perception of them, or control your stress response. By being kind to yourself, you can reduce the negative or distorted cognitive patterns in life balance. Overgeneralisation, catastrophic thinking, maximise negatives and minimise positives, all or nothing thinking, mindreading, fortune telling, personalisation and a selective negative focus are all unhelpful patterns, yet things many of us do. Maybe you secretly enjoy helping people who are suffering, and enjoy the drama – read this blog on co-dependency by St Emlyns to explore that further.
Resolve conflict with yourself and your friends and colleagues. You might have inner conflict that you’re not good enough to be a Doctor, or you might have a different conflict that you should be spending more (or less) time with family – and some of this results from not knowing or being true to yourself. Self identity is really important. Be kind to yourself – and be your own Compassionate Friend. Matthew Syed in his Sideways podcasts talks about how it’s easier sometimes to have an alter-ego who can be the super-hero. Create your alter – ego, but what would they say to you, and what would you say to them? Would you say “you handled that really badly”? Or would you say “you handled that well, and you might like to consider being kinder next time”. We listen to you more than I.
Enjoy this brief “compassionate friend” exercise:
- Close your eyes and remember a recent time when you had self criticism
- Imagine something to symbolise the critical voice – listen to what it says – notice tonality – notice how it makes you feel
- Imagine something to represent the strong, compassionate friend part of yourself – listen to what that part is saying – notice the tonality and how it makes you feel.
- Which is working better to encourage you to do better?
- Practice until your compassionate friend activates as easily as your self criticism!
Turning off the technology to give yourself a tech break is really really important – take your emails off your phone, don’t log on, whatsapp for social only – and don’t connect. If something bad is happening, don’t listen to the news – it’ll only make you more stressed.
4. Have a physical break
Give yourself a physical break – have a change of scenery. Always plan a holiday – use the Tarzan principle and swing from holiday to holiday. I know COVID has meant we can’t travel as much – but have a holiday at home. Cycle to work one day instead of driving – or get an Uber instead of a drive.
The physical break also gives you a chance not to be at work. Are you an “alholic”? Maybe the careaholic who gets overly involved with worrying about others. The workaholic- thinking about work all the time. The busyaholic – constantly on the go, yet not meaningfully engaged in anything? The Rushaholic – always speeding up, but not noticing what is going on around you? Maybe you prefer to think of your excesses in less addictive terms. Are you a Busy Bee gaining satisfaction from the fast pace of life? Are you an endurer, compromising yourself to get the obligatory tasks done? Are you a deferrer seeing the light at the end of the tunnel? Are you an outsourcer or a resister?
This physical break should be done daily – not a holiday every day, but a break from technology or work. Lots of places developed leaving checklists that focussed on leaving work at work, and enabling home to be home – should turn email off be on the list?
Normalise not having your email on your phone.
— Tessa Davis (@TessaRDavis) August 18, 2021
5. Appraisal and support
We mentioned before that the appraisal can be a useful way of talking about wellbeing with your appraiser – tell your colleagues how useful you found it, and tell your appraiser how wonderful it was, to get the conversation started. Share your experiences of burnout or rust out. Talk about the resources available for everyone – and access as needed. As a reminder, there’s BMA Counselling, and the Practitioner Health Programme available to everyone, as well as more resources linked to on our COVID blog and your trust will also have lots of resources available.
6. Your Department
We mentioned above how your department can begin to prevent burnout. Your department is likely to be a “volatile, uncertain, complex and ambiguous environment”. In these VUCA environments, psychologically safe leadership is essential – have a read of this HorizonsNHS report for more information.
If someone is absent from burnout, PIES is a framework for discussion that could be useful. Return to work interviews are mandatory in many places, but sporadically and badly completed. PIES is one frame work that can be really useful for supporting a colleague.
Proximity – if possible, try to keep colleagues working within the team (rather than going off sick), but reduce stress (e.g. through a temporary change of role) – this helps people to continue feeling valuable. It can be hard to return to work after a period of absence, so staying at work may support someone better.
Immediacy – address concerns straight away – use a ‘nip it in the bud’ approach
Expectancy – acknowledge that things may be tough for a while, but also that they will get better
Simplicity – if you are in a crisis and having a difficult time, it is often the simple things that help e.g. having a day off, having a good night’s sleep, eating well, phoning a friend
7. Treating Burnout
If you are burntout, you will get through this, and it will get better. Make a start today – and every step is a step forward. Stop what you need to stop, start what you need to start, and connect with the connections you need – occupational health, staff counselling, practitioner health, GP etc.
Whether you are or are not burnt out, now’s a good time to do a body scan. Close your eyes, and start at your head. Take a few nice deep breaths, then run through and review. Notice your body, and correct any problems. Move down towards your toes. Well done.
Other Organisations that can help
- Occupational Health Service – If you think that your health problem/s (physical or psychological) are affecting your ability to work, your manager can refer you for advice and support. Most hospitals let you self-refer to the Occupational Health Service.
- Employee Assistance Programme is available 24/7 at most hospitals.
- Chaplaincy Service – The chaplaincy service is there to support staff as well as patients and are equipped to cater for a range of spiritual beliefs.
- Primary Care Psychological Therapy – Increasing Access to Psychological Therapy (IAPT) services are NHS primary care psychology services available across the UK, providing evidence-based psychological therapy. You can generally self-refer via online referral forms, or you can visit your GP and ask for a referral.
- Keeping Well SEL Portal: Support for health and social care staff across SE London including online chat with trained MH professionals, fast track access to primary care psychology (IAPT) and lots of self-help resources. www.keepingwellsel.nhs.uk
- NHS People: Range of support provided by NHS England including: Phone support: 0800 06 96 222
Text support: Text “FRONTLINE” to 85258
www.people.nhs.uk – for a range of support options including apps, groups, financial support and support for alcohol and substance issues.
- Frontline19: Free psychological support service for staff working on the frontline. Fill in the form on their website to book an appointment https://www.frontline19.com/
- Body and Soul: Free crisis counselling for frontline staff and family. Request a call back on the website: https://bodyandsoulcharity.bookinglive.com/
- GP: Your GP will be able to refer you on to more specialist services where necessary and may have information on other forms of support available to you in your local area.
- Tea and Empathy: Facebook group for health professionals to provide informal peer support to each other. Search for “Tea and Empathy” on Facebook
- National Suicide Prevention Helpline UK – Offers a supportive listening service to anyone with thoughts of suicide 24/7. 0800 689 5652 https://www.spbristol.org/NSPHUK
- Samaritans: Confidential, impartial support. Call: 116123 firstname.lastname@example.org
SUPPORT FOR NURSES
Royal College of Nursing Counselling Service: 0345 772 6100
Nursing and Midwifery Council FtP Careline: Support line for nurses and midwives going through a fitness to practice process.
0800 587 7396 https://www.nmc.org.uk/ftpcareline
SUPPORT FOR DOCTORS, DENTISTS & SURGEONS
NHS Practitioner Health Programme: Provides specialist support to doctors and dentists. 0300 0303 300 email@example.com https://www.practitionerhealth.nhs.uk/
British Medical Association Wellbeing Support Service
0330 123 1245 firstname.lastname@example.org
Doctors in Distress: A charity committed to eradicating stigma, change behaviours & cultures and promote the value of good leadership to reduce suicide rates of medical doctors. https://doctors-in-distress.org.uk/
Surgeon to Surgeon Helpline: Confidential peer support for surgeons run by the Royal College of Surgeons 020 7869 6221 https://www.rcseng.ac.uk/careers-in-surgery/csas/
Doctors Support Network: An independent, confidential and friendly self-help group run by doctors and for doctors who have experienced mental distress or mental health problems. email@example.com https://www.dsn.org.uk/
Sick Doctors Trust: Support and help for doctors, dentists and medical students who are concerned about their use of drugs or alcohol.
Doctors: 0370 444 5163 Dentists: 020 7224 4671
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Further Reading and Resources
- Challenging Stress, Burnout and Rust Out – a useful overview with lots of good ideas. Recommended.
- Mental Health and Wellbeing in the Workplace