There’s a risk that individuals blame themselves, when it’s the system that has left all of us exposed
Mariam Alexander is an NHS consultant liaison psychiatrist
o state the blindingly obvious, this has been a shocking year for those of us who work in the NHS. We have been under relentless pressure to respond to the new challenges created by Covid-19, stretching ourselves both professionally and personally.
I work in liaison psychiatry, a discipline that provides mental healthcare for patients who may have come into hospital for other reasons. Like many of my colleagues, I have been drawn into supporting NHS staff’s wellbeing, expanding my expertise to help those bearing the brunt of the pandemic’s clinical workload.
There has been much talk of burnout – a concept first described in scientific literature in the 1970s and one that has subsequently been a topic of debate among scientists and clinicians: does it exist? How should we define it? What’s its significance?
The World Health Organization (WHO) defined burnout in its latest version of the International Classification of Diseases (ICD-11) as “a syndrome conceptualised as resulting from chronic workplace stress which has not been successfully managed”. It goes on to describe three main dimensions of burnout: low energy levels; feeling negative, disconnected or cynical about work; and a sense of being professionally ineffective. The controversial nature of the idea was made clear by the fact the WHO issued an urgent clarification stating that burnout was “an occupational phenomenon … not a medical condition”.
As a psychiatrist, I welcome anything that helps us to better understand how our experiences shape our mental health. While there is much to be said for the concept of burnout, my concern is that it includes the implication that the problem lies with the individual not coping with their work rather than the work itself being unmanageable. After all, if your house is on fire and you get burnt, the problem lies with the burning house, not you.
Everyone working in the NHS is feeling the heat of the pandemic. We’re used to dealing with stressful situations but the past year has posed challenges like no other. The list is long, but it’s worth setting out some of the challenges: the sheer scale of the distress and trauma; witnessing so many people dying before their time; worrying about getting Covid yourself and passing it on to loved ones; seeing colleagues becoming critically ill and dying due to Covid; keeping up with ever-changing scientific knowledge and policy guidance; managing the uncertainty of redeployment; coping with even more magnified staff shortages; receiving hostility from a small but powerful section of the public; dealing with the moral injury due to having to manage the greatest health crisis of our time using already depleted resources.
It’s common to come across healthcare staff who think they’re not good enough at their job when actually it’s the system that is not good enough. One of the dangers of not appreciating this wider picture is that it can create a barrier to recognising and talking about how difficult things are, particularly in what can often be a highly competitive world. We feel an enormous sense of responsibility, not only to our patients but to our colleagues too. We don’t want to let the team down and so we work harder and longer, doing what we can to make up for shortfalls even though this can come at great personal cost.
As a psychiatrist, the patients I worry about most are those who are unable or unwilling to talk to others about what’s on their mind – because if they don’t, it’s all too easy to lose perspective, and dark thoughts can become much darker. I urge patients and colleagues alike to ensure they have at least one person they can talk to openly and honestly, and if they don’t have this in their personal lives to seek it out from a professional.
A number of resources are available to support NHS staff during the pandemic. However, it’s clear that some who might benefit from such support are reluctant to seek it. Some don’t recognise the need. Some are in survival mode and don’t want to think about the emotional impact of what they’ve been through for fear it might make them fall apart when there is still so much work to do. Some worry that seeking help would be perceived as evidence of incompetence or mental illness.
There is indeed a risk of unnecessarily pathologising the experiences of healthcare staff. Yes, there are those who develop a mental illness such as PTSD due to the trauma they have experienced during the pandemic. But for others, their distress is an entirely expected response to the sustained work pressure – finding things difficult in the context of a pandemic is not a sign of weakness, it’s a sign of being human. We need to create a work culture where we value the wellbeing of all staff rather than waiting for people to become unwell before we do anything about it.
The reality is that prioritising this is going to take time and money. With things as stretched as they are, it can seem like there’s tension between looking after the needs of staff versus looking after the needs of patients. However, these are actually one and the same thing. The NHS staff survey repeatedly tells us that the more healthy and engaged the workforce is, the better the quality of care patients get.
Many NHS staff fear we will be expected to lurch from one crisis to another – from Covid to tackling the enormous waiting lists for non-Covid work. We want to ease the pain and suffering of those who are waiting for the care we know they desperately need, but we are also exhausted and need to recover.
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Once the dust begins to settle, and the strong pull of duty to respond to an emergency wanes, many are concerned that there will be exodus of burnt-out staff from the NHS. Some taking the opportunity of early retirement. Some seeking work in the private healthcare sector. Some leaving healthcare entirely, deciding there are less stressful ways to earn a living. Some heading off to countries such as Australia and New Zealand in the belief that they offer better pay and conditions, and that these governments have responded to the pandemic more effectively.
It’s not all doom and gloom though. It can be strangely soothing to be in the thick of a Covid-ridden emergency department – there can be a strong sense of connection, pride and purpose among staff. And for people who love to learn there have been plenty of opportunities, not only around our scientific understanding of Covid, but also about how we as individuals and a system can adapt to the demands of a monumental health challenge. Many of us have also felt enormously appreciated by the communities we serve.
There is, of course, always a place for individual responsibility. But it’s vital we create a work culture that encourages self-awareness rather than self-criticism. There may well be individuals who are more susceptible to burnout. But they are not the “weaker” ones. They’re the canaries in the coal mine telling us something is wrong with the system. The lesson is to improve the NHS to make it healthier for all of us.
Mariam Alexander is an NHS consultant liaison psychiatrist