Feeling the fear… and not doing it anymore
Intolerable fear and anxiety among healthcare professionals is fuelling burnout. What is driving this and how can it be addressed?
While a reasonable level of fear and anxiety is part and parcel of working in healthcare – even boosting performance where clinicians rise to specific short-term challenges – sustained psychological anguish is a key driver of burnout.
Recent research shows that 31% of doctors worldwide are experiencing “moderate to extreme” fear at work – which is increasing in line with patient demand, expectations and extraordinary levels of “moral distress”; healthcare professionals (HCPs) feel unable to make the right calls for the people in their care due to factors outside their control.
The NHS has previously been accused of harbouring a blame culture, fuelled in part by cases that have highlighted a lack of trust between clinicians and non-clinical management, plus increasing complaints and litigation – amplified by the media – add to the burden on doctors. Workplace bullying and stigma around mental health are fear factors that prevent clinicians from seeking help.
London-based locum GP Dr Sophie Redlin has noted the “rising levels of litigation and a real environment of people being dragged through the wringer when mistakes happen. When coupled with the struggles the system is facing and the circumstances we’re working in, it’s terrifying,” she admits. “I’ve had two people this week shout at me about the state of the NHS.”
Anxiety rife in the NHS even before Covid-19
Anxiety is sometimes described as a generalised response to an unknown threat (or internal conflict), whereas fear is focused on known external danger. The former can be particularly damaging because it continues relentlessly without resolution. Others see fear as a simple escalation of anxiety.
Either way, when fear or anxiety are excessive and chronic, they cause physical, psychological and behavioural symptoms. For example, panic attacks, a racing heart and tight chest, catastrophising or obsessive thinking, and avoidance of situations that might increase anxiety. They can impact physical and emotional health and adversely affect memory and decision-making.
During Covid-19, there is no doubt that fear and anxiety – around contracting or spreading the virus and being expected to make impossible decisions about how to use limited resources – became a constant for HCPs.
But, as with other aspects of burnout, the trend was apparent well before the onset of the pandemic.
In a 2019 BMJ.com article titled Fear in medical practice, Professor David Oliver, a consultant in geriatrics and internal medicine, painted a vivid picture of the “systemic, endemic, interpersonal, environmental and sociocultural” drivers behind fear and anxiety in the NHS.
“A continually under-resourced, short-staffed system, increasingly unable to meet rising demand, begins to feel unsafe,” he warned.
“Care can be rushed or missed. There’s relentless pressure to discharge people or prevent them being admitted. The sheer number of patients and families we support each day, and the imperative to work at speed and minimise delays, means corner cutting and workarounds.
“We have to accept, balance and mitigate risk to patients, even as systems outside hospital are under even more strain. We work on wards facing epic nursing shortfalls, often with inadequate IT or logistics. Even if our own decisions and communication are sound, there’s much else we can’t control.
“Add to this the growing complexity of patients on our caseload, relentless political and media scrutiny of the NHS, and growing public expectation and dissatisfaction (often with aspects of care we have no power over) and anxiety seems inevitable.”
Like Redlin, he highlighted the fear of regulatory action, plus anxiety around not being able to keep up to date with knowledge and skills; the fear of finding oneself turning to addictive behaviours to cope – and then losing everything.
He explained: “When generalised chronic anxiety takes hold, some worries can be blown out of proportion so that we lose our peace of mind – not from what has happened but from what we imagine might happen.”
HCPs battle with uncertainty and alienation
Behind much of this fear lies uncertainty – which, today, goes far beyond the uncertainty inherent in clinical decision-making.
As East London GP Dr Jonathon Tomlinson explains: “There are particular types of uncertainty which are somewhat unprecedented. There’s uncertainty around whether or not your patient’s ever going to be seen; whether their tests will be done in the near future; whether their drugs will be available at the pharmacy. It’s uncertain whether they’ll have enough money to pick up a prescription or get to the hospital.”
But Tomlinson flags the inherent alienation and isolation in modern healthcare as the overwhelming causes of anxiety, in his experience. “The thing that’s especially anxious-making is working at a high intensity of decision-making with too little time to stop and think and speak to anyone else; to share your decisions with others,” he says.
He believes that today’s HCPs are alienated from the reasons why they wanted to go into medicine in the first place and from their patients (being stuck behind virtual interfaces, “a slave to computers and contracts, which are satisfied by ticking boxes on a screen”). Doctors are also alienated from the end results of their efforts (being reduced to cogs in the NHS machine, rather than treating patients holistically) and from each other – lacking the time or opportunities to interact and share.
He would like to see less box-ticking, inspection and regulation and more collaborative partnerships with patients. Instead, he says, “we are left alone to carry lots of risk”.
Dr Redlin points out that this burden of risk, and a fear of complaints, may lead to suboptimal judgements. “I’m afraid to say that a lot of our decision-making is driven by fear; a feeling of ‘I don’t want to be in trouble’ – which isn’t always good clinically.”
She agrees that general practice can feel isolating and that “a lot of our focus now is on meeting parameters and targets”.
To help address the isolation and anxiety associated with the current epidemic of moral injury, Redlin, who is also a mental health researcher and trainer at 4 Mental Health, has co-founded a retreat to help raise awareness of the phenomenon, reduce stigma and share coping strategies.
“There’s a lot we can’t change, so it’s about building community in the places where we work; finding mentors, time to talk about things throughout the day. In our retreats, we try to create an equal space and make people realise that it’s more about being a human being than being a nurse versus a doctor.”
Health services, however, cannot leave it up to clinicians to address the causes and symptoms of fear and anxiety. Building personal resilience is a good thing, but with a worldwide shortage of HCPs, we need to take action to address long standing systemic problems – and fast.
Proprietary data is provided by Havas Lynx Group, Point.1, 2023, unless stated otherwise.
The mental health pandemic plaguing healthcare professionals
Healthcare workers and doctors are suffering burnout in an environment that lacks the resources and will to support them. Charity Doctors in Distress is stepping in to offer solace to those affected and help raise awareness of the crisis
When duty, burnout, fear of failure, exhaustion, a blame culture and a lack of support collide, the effects can be lethal. And, sadly, this toxic combination of factors is not uncommon among NHS healthcare professionals.
Dr Jagdip Sidhu was a consultant cardiologist who died by suicide in 2018, aged 47, when work-related pressures became overwhelming and there was no support structure in place to help him.
His brother, Amandip, describes the situation in which Dr Sidhu found himself and how it led Amandip to set up Doctors in Distress, a charity that works to raise awareness of the issues faced by healthcare professionals (HCPs) and provide practical support to protect mental health and stop suicide in all healthcare workers, not just doctors.
“It appears that my brother had a significant level of burnout. But like many in the medical profession, he hid it very, very well,” says Amandip, who has also experienced burnout. “Things came to a head just before he passed away. He was doing the job of two consultants at the time – one of his colleagues was off sick, long term, with a health issue. Being the sort of person he was, Jagdip said, ‘Right, I’m going to step up and show everyone how well I can do.’ But, ultimately, he succumbed.” There was no appropriate management in place to supervise him and ensure safe working practices.
Amandip describes his brother as a “nervous, shaking wreck” during the final days of his life. He had been signed off sick and was living in fear of not being allowed back to work, telling Amandip that he needed to find another job because he believed that his workplace “would never let him back in” and “would crucify and speak badly about him”. Jagdip was found at Beachy Head shortly after this, his death sending shockwaves through the lives of his family, friends and colleagues.
“I discovered very quickly that this was something that, although it was tragic and seemed unique, was happening to other people," says Amandip. “Other people covered it up and didn’t really want to speak about it. I believe – given the way that my brother died, and where he died, particularly – that he wanted to send a very clear message to say, ‘Look what happened to me.’ I felt duty-bound to continue that message and hopefully encourage people to learn from what happened. I didn’t want people to feel there was nowhere to turn to when they were alone and isolated, which my brother clearly felt.”
Exhaustion and burnout
The statistics around the mental health of doctors and HCPs are catastrophic. Recent estimates suggest that one nurse takes their own life every three days and one doctor does so every three weeks, the true figures are likely to be higher. The NHS Staff Survey results from 2022 show that 34% of staff said they often or always felt burnt out because of their work and 37% said they often or always found their work emotionally exhausting.
In addition to this, recent data from Point.1, Havas Lynx Group’s proprietary data product, found that almost one-quarter (24%) of healthcare professionals experience more negative emotions at work compared with the general population, with 31% of the 2,536 HCPs sampled, experiencing moderate to extreme fear at work.
Amandip, a pharmacist, studied the phenomenon within the medical and healthcare professions and many commonalities with character traits, such as perfectionism and a desire to help others, coupled with a challenging workplace culture, conspire to cause distress – with a lack of any support exacerbating the problem.
The pandemic – and the new attention it brought to those toiling as many remained at home, changed the general perception of healthcare workers and helped to bring the charity's message to the fore.
“It put a spotlight on, and amplified, our message, to say: ‘look after yourselves,’” explains Amandip. “We started providing support groups and information about the solutions that we offer. But to summarise what the charity does, we’re all pretty much agreed as a board of trustees and team that we’re there to protect doctors’ and healthcare workers’ mental health. We want to stop burnout and prevent suicide in the medical and healthcare professions, and develop and provide initiatives that will intervene and continue to protect their mental health.”
Doctors in Distress, which was founded in 2019, wants every NHS doctor and healthcare worker to have access to mental health support in the workplace. This, stresses Amandip, must be funded and made available during working hours. As a minimum, there must be at least one hour a month of reflective time when doctors and healthcare workers can ‘off-load’ and talk confidentially about the impact of their work in a non-judgemental environment, without fear of shame and retribution, he adds.
“The second thing is making sure that the NHS is a good place to work in again,” he says. “A lot of people are saying that they’re burnt out. If I heard that in a private company or institution and I was the founder or owner, I’d be quite upset. In order for us to have a very long-term, sustainable and effective NHS, we have to put the staff at its core.
“It seems to be that adverse mental health and suicide are an occupational hazard. It’s being talked about more, and that’s great. But in some ways, it’s become ‘the norm’, it’s acceptable. That said, this is a complex issue and there isn’t any particular one that will make this go away. What’s happening is the sign of a creaking health system.”
While Amandip acknowledges that there is no simple way to ensure doctors’ and healthcare professionals’ wellbeing in an organisation as large, and with as many divisions and employees as the NHS, he says Doctors in Distress has met a need for support in 2,500 people to date, providing a safe space for all healthcare workers through its online peer support groups.
He says: “People have reached out and said, ‘I would have ended up like your brother had this not been in existence. Thank you.’ So, you know, we're doing the right thing. And that's what keeps me and the entire team going.”
Doctors in Distress is committed to promoting and protecting the mental health of our healthcare workers and preventing suicide. Please give so we can care for those who care for us.
Doctors and healthcare workers are facing unprecedented pressure – it's essential that we look after the people who help us, before it's too late
Burnout: the people hardest hit and the price they pay
Chronic stress that has not been properly managed is an occupational hazard for healthcare professionals – particularly for women and minority groups
“Professional burnout is the accumulation of hundreds or thousands of tiny disappointments, each one hardly noticeable on its own.”
So wrote Richard Gunderman, a professor of radiology and philosophy at Indiana University, in a 2014 edition of The Atlantic, succinctly capturing the insidious nature of this creeping condition.
It’s no wonder, then, that burnout proliferates in healthcare, where demand and workload are spiralling, resourcing is inadequate and cultures are described as “archaic”.
Even before Covid-19 brought health services to the brink, this “occupational phenomenon” was reported to affect one in three doctors, crossing sectors and specialties.
It manifests as exhaustion, increased mental distance from one’s job and reduced professional efficacy. But for many doctors (who have spent decades training) it feels like inadequacy and failure – and an erosion of identity.
If left unchecked, burnout can cause irrevocable damage to emotional, mental and physical health, ruining careers and undermining healthcare.
The impact of ‘moral distress’
In the UK in 2023, 57% of doctors say their work is “emotionally exhausting to a high degree”, according to the Workplace Experiences survey by the General Medical Council (GMC), and 25% are at “high risk of burnout”; 44% say they find it difficult to provide sufficient patient care at least once a week, compared to 25% in 2021.
“The burnout epidemic isn’t something that’s ahead of us, it’s already here,” attests BMA workforce lead Dr Latifa Patel. “We have 112,000 unfilled vacancies in NHS England alone and 7.8 million people on the waiting list. That’s never not going to lead to burnout and pressure.”
She asserts that recent strikes by UK doctors, nurses and paramedics are as much about conditions as they are about pay. Healthcare professionals (HCPs) are demoralised by their inability to care for their patients the way they would like to, experiencing ‘moral distress’ when they feel unable to take ethically correct actions.
As a paediatric respiratory junior doctor, Patel understands how draining it can be to ‘fail’ your patients, day after day.
“Imagine how it feels when every patient you see in a 13-hour shift, you should have seen sooner,” she says. “So, to every single person, you’re having to say, ‘I’m sorry’. Try that for a day. It makes you feel unvalued; as if you’re not achieving to your best.”
Also debilitating is the lack of basic staff facilities, from lockers and rest areas to parking and food. Wellbeing hubs were introduced during the pandemic – but then removed, as if HCP wellbeing were no longer in doubt.
“We’re people, not superhumans,” emphasises Patel. “If you’re on a night shift, the only sustenance you can get is a chocolate bar or a packet of crisps. It’s the opposite of a caring environment.”
She recalls having to change into scrubs in toilets, leaving belongings in a bag and “hoping it didn’t get stolen”. She adds that doctors who are breastfeeding end up expressing their milk in toilets, due to a lack of dedicated facilities.
This is just one small example of the cultural problems that abound for women, who typically still take care of the majority of family responsibilities. For parents and carers, the system lacks flexibility and empathy; staff on rotas have minimal autonomy over their own lives. Women may have to choose specialties that best cater for part-time work rather than pursuing their real interests or talents.
Given this, it’s hardly surprising that burnout in female physicians may be up to 60% greater than in males, with women scoring higher for emotional exhaustion. Despite women making up 75% of the NHS workforce, healthcare remains designed around the needs of men.
Even the PPE used during the pandemic was tailored to men, points out ENT surgeon Dr Laura Dias. “There’s plenty of evidence that women and people of colour are more at risk of burnout. The reason’s obvious: high levels of misogyny, racism and discrimination. It’s a cumulative effect; you have day-on-day microaggressions – it’s tiring.”
“For example, you’re not given as much respect by colleagues or patients,” she explains. “When people say that ‘as a woman you have to work twice as hard’ it’s true. As a woman of colour, you have to double that again.”
This is visible in the fact that doctors from ethnic minorities are twice as likely to be referred to the GMC by their employers for fitness to practise concerns than white doctors, while the referral rate for doctors qualifying outside of the UK is three times higher than for UK doctors. The GMC itself has set targets to address disproportionate complaints.
Dias, who is now an ambassador for the charity ‘You Okay, Doc?’, has experience of working in a male-dominated specialty as a woman of colour – and of burnout. In 2017, she reached a crisis point and took extended leave to rethink her priorities.
For years, she’d been working seven-day weeks, “cutting out social contact and not making time for her own health”, but when she broke down, she was overcome by shame.
“It took me a long time to process and understand it,” she says, “Before then, I was the kind of surgeon who thought of others as not dedicated if they didn’t come in every single day. That’s wrong – and it’s easy to see that on the other side.” With hindsight, she also recognises the toll burnout took on her judgement and decision-making.
Now back at work and pursuing her career, she is helping to educate HCPs about wellbeing and to provide safe spaces for clinicians to talk about their experiences.
But while self-care strategies are valuable, Dias stresses that “burnout is the definition of a workplace problem” – a systemic issue rather than an individualised one. It requires targeted investment and cultural change.
Initiatives such as ‘clap for heroes’ and ‘gratitude ponchos’ are not about wellbeing, she stresses.
“Real wellbeing is feeling safe in your workplace; being warm, being able to park, not suffering sexism or racism, being paid enough, having your rota months in advance and knowing you’ll be able to attend your own wedding; it’s having a place to rest or access to food,” she says.
In other words, preventing burnout is about identifying the hundreds or thousands of “tiny disappointments” that build over time to bring HCPs to their knees – and addressing the systemic root causes. “It will take doctors and nurses to say, ‘That’s not how I’m going to work,’” says Dias.
Proprietary data is provided by Havas Lynx Group, Point.1, 2023, unless stated otherwise.
Healing the healers to save healthcare provision
Every stakeholder has a role to play in addressing clinician burnout – from policymakers to patients and pharma
“Health is like money; we never have a true idea of its value until we lose it,” said the 19th-century American humorist Josh Billings. The same could be said of our healthcare services.
In fact, it is being said – by the General Medical Council (GMC), the British Medical Association, the Royal College of Nursing and many other healthcare bodies worldwide. In June, the GMC reported that 15% of doctors were taking “hard steps” to leave the NHS, asserting that “urgent action is needed to break a ‘vicious cycle’ of unmanageable workloads, dissatisfaction and burnout.”
But this trend is neither UK-only nor specific to doctors. The growing exodus is mirrored across countries, disciplines, sectors and seniority levels. The World Health Organization (WHO) projects a shortfall of 10 million healthcare professionals (HCPs) by 2030.
Burnout – described by WHO as “chronic workplace stress which has not been successfully managed” – is decimating clinician wellbeing, while undermining patient care, outcomes and trust. It’s a systemic problem that requires systemic solutions.
A tsunami of burnout
To help galvanise action, healthcare communications agency Havas Lynx Group has used its proprietary data solution, Point.1, to shine a light on healthcare professional attitudes, beliefs, behaviours and influences.
This involved analysing the most comprehensive data set on physicians outside the US, drawing on a sample of 2,536 HCPs. The resulting white paper, Healing the Healers, presents an array of telling statistics.
For example, HCPs experience 24% more negative emotions at work compared with the general population; 43% of HCPs experience moderate to severe distress at work and 31% experience moderate to extreme fear.
Almost a quarter (24%) of physicians globally agree that they will leave direct patient care in the next five years. The rate of suicide in HCPs is between five and seven times higher that of the general public.
“Healthcare systems on a global scale are on the brink of collapsing,” warns Havas Lynx Group CEO Claire Knapp. She is calling on the public, healthcare organisations, policymakers, governments, and pharmaceutical and biotech companies to each play their part in effecting change.
“If we don’t address burnout, we’ll continue to see HCPs leaving healthcare, longer waiting times, a further decline in patient outcomes and an increase in mortality,” she says. “The cost to HCPs will be higher levels of suicide, depression and addictive behaviours. All this undermines the stability and resilience of our healthcare system and causes a slow deterioration.”
She explains that burnout crosses boundaries and disciplines (affecting nurses and pharmacists as well as doctors) but is notably rife in emergency medicine, surgery, obstetrics, gynaecology and general practice. “Millennial HCPs feel less able to cope than their Boomer counterparts, which suggests it’s going to be an increasing issue,” she adds.
“There’s also a clear link between equity, diversity and inclusivity (EDI) and burnout, almost certainly because of systemic and historic discrimination and inequality.”
Multiple drivers, multiple solutions
Burnout affects HCPs on physical, emotional and social levels; it causes illness and addictions, can ruin relationships and destroy careers. Symptoms include exhaustion, ‘depersonalisation’ and reduced professional efficacy. These undermine memory and decision-making, seriously impacting patient outcomes.
Addressing it means “acknowledging the problem, minimising causes and consequences, removing barriers to identifying solutions, and ultimately championing the change and support essential for our HCPs,” explains Knapp.
There is no single reason for burnout – and it wasn’t caused, only exacerbated, by Covid-19, emphasises Havas Lynx Group medical director Tapas Mukherjee, a former NHS doctor.
Rather, there are multiple drivers, ranging from impossible workload to spiralling bureaucracy, professional alienation and compassion fatigue. Unreasonable patient expectations, unfair rewards and a fear of litigation combine to take their toll.
At a government level, there is no doubt that underfunding in healthcare needs addressing – and fast. It’s a direct contributor to the ‘moral distress’ experienced by health professionals (whereby they identify the right course of action but are constrained in their ability to take it). Research shows that 21% of physicians will have experienced moderate-to-extreme feelings of guilt in the past seven days at work.
Guilt and fear may be heightened by media negativity, and reports that focus on the consequences of burnout without acknowledging the underlying problems. Conversely, as during Covid-19, HCPs may be portrayed as superhuman – only adding to unrealistic expectations.
Patients need to be helped to use services responsibly and not take out their frustrations on overstretched staff. There is a space for this kind of education to be delivered through responsible coverage by the media. Mukherjee argues that education could also feature in the role of the pharmaceutical industry, highlighting the wealth of “knowledge and excellence within pharma”. Studies have shown that almost three-quarters (73%) of HCPs say that pharma and biotech companies should add value to society as a whole.
“We saw some of that during the pandemic,” he explains. “It would be great if there was more acceptance of working together and learning from each other.” A practical example of this would be helping HCPs to absorb high quantities of new data and literature, which now doubles every 73 days.
“Sales reps could even be trained as ‘mental health first aiders’,” suggests Knapp. “Instead of opening with questions about their drug, asking ‘How are you doing today, doctor? What could we be doing to support you?’”
To assume that all HCPs already have access to emotional support would be overly optimistic. Barriers to better mental health are organisational, psychological and socio-cultural. They include a lack of occupational health services, stigma and a culture of presenteeism.
These obstacles need dismantling with the help of leadership and role-modelling at an organisational level. “Archaic” cultures must change in line with the corporate world where flexibility is embraced and wellbeing is prioritised.
“Organisations have to understand that it’s okay for HCPs to have emotions; it’s also okay for them to have children... and not to work full time,” stresses Mukherjee. It boils down to “recognising that doctors are human”.
Doing so involves treating HCPs with the level of empathy we hope to receive as patients – and committing to change from the top down and the bottom up.
“It’s time for collaborative, progressive thinking that can help tackle the challenge,” concludes Knapp. “We’re only successful if we can reverse this trend.”
Proprietary data is provided by Havas Lynx Group, Point.1, 2023, unless stated otherwise