A Resilient NHS?

There was no shortage of self-confessed wounded healers at yesterday’s Wounded Healer conference. Professor Jill Maben, who gave the first keynote, confessed that she had to leave her first nursing post because of stress, and I met many doctors and nurses throughout the day who had their own personal stories. Several, like Jill Maben were presenting or leading workshops, and others were there to find better ways for themselves and their colleagues to cope.

In her research Jill followed up nurses from training into qualified posts and discovered that their ideals were sustained, compromised or crushed by the pressures of work [1]. The compromised idealists who were unable to provide the compassionate, patient-focused care they aspired to, were the most distressed and this resonated with everyone in the audience, whether doctors, nurses, managers or patients. In their excellent review of compassionate care, Cole King and Gilbert explain that whilst empathy gives us the capacity to understand another’s suffering, compassion gives us the motivation and desire to relieve it [2]. When the ability to relieve suffering is compromised, it is not only patients, but also health professionals who suffer. In order to protect themselves, Maben discovered that nurses who were suffering focused on ‘poppets’, patients who were less complex and more rewarding to care for.

Health professionals enjoy hard work. Professor Ivan Robertson, in the second keynote explained that demanding work is satisfying only if it is matched by adequate support, resources and control. I found it very helpful later in the day to apply this during a session about burnout and resilience in general practice. When GPs are feeling burned out we should ask, ‘what are we missing in terms of support, resources and control?’

Support

Many GPs feel unsupported and isolated. The intensity of work, combined with every task being delivered to the computer in the doctor’s consulting room, means that it is possible for a GP to spend all day behind a closed door and have no interaction with anyone else in their practice. We discussed strategies like enforced coffee breaks, working duty or administrative sessions in shared offices, and meeting before surgery starts to ensure everyone could get together. We all agreed that narrative-based clinical supervision for all health professionals would help [3]. The importance of different members of the practice team understanding the lived experience of each other’s work mirrored Havi Carel’s concern that health professionals should try harder to appreciate what it is like to be a patient [4]. There was a lot of enthusiasm for Schwartz rounds where anyone involved in patient care, from secretaries to hospital porters, nurses and consultants share stories about the emotional labour of care [5–8]. I have a study group of six GPs, some of whom I did my postgraduate training with over 15 years ago, that meets every three weeks on a Sunday afternoon and has been invaluable in times of difficulty.

Resources

Lack of resources is a very common complaint. The lack of money hangs over almost everything. A blog from Professor Chris Ham of the Kings Fund the day before the conference accused the Treasury of denying the scale of the NHS funding shortfall. Many of us who work in the NHS feel a mixture of fury, dismay and despair at the cuts to NHS services over which we have no control. Human resources are a related concern and in nursing the very high turnover of staff, dependency on agency staff, reliance of under-qualified staff and under-staffing are all demoralising. There is also no chance that numbers of GPs will increase sufficiently in the near future so it seems that almost everybody in the NHS is expected to work beyond their capacity. Material resources may be in short supply and we need easy access to all the necessary equipment, which is too often missing or not fit for purpose, especially IT [9].

Control

At first sight, there appears to be a contradiction because we enjoy, compared to many of our patients a lot of privilege and control over our working lives and yet are still at high risk of burnout [10,11]. In searching for the elusive resilience, it is helpful to think about the support and resources over which we do have some control and doing what we can. Nevertheless, as the imposed junior doctors’ contract with a 20% pay cut this week demonstrated, salaried state employees have little say over their terms and conditions. For GPs, who may be self-employed, the impact of our increasingly dense and numerous appraisals, inspections, compulsory trainings, care pathways and performance indicators, is tiring and demotivating [12].

Individuals and organisations

The first and perhaps most important point to note is that when healthcare professional is burned (or burning) out, they are akin a canary in a mine, they are a sign that the organisation is in trouble. Colluding with the idea that the problem lies with an individual removes the responsibility for the organisation to look at systemic issues. If we take the canary analogy, it may be possible to spot the early signs of an organisational problem before the canary keels over or the doctor goes off sick. GPs at the Wounded Healer conference bought up examples of early signs including – increased complaints about a doctor, increased referral rates, working unusually excessive hours, seeing patients outside of clinics – especially the same patient(s) frequently, failing to keep up with admin, etc. Changes to mood or personality especially cynicism and depersonalisation and physical changes like insomnia or weight change, or excessive drinking are common. Nevertheless there may be no signs at all, because when doctors are sick, work is almost always the last bit of their lives still standing. Severely depressed doctors are able to consult in ways that are not recognisably different to their patients and doctors use their ability to continue working to deny the reality of their illness. Sick doctors hang on very tightly to their resilient, healthy, cope-with-anything, professional identity [13]. Shame and stigma are felt very strongly by doctors who suffer with physical and mental illnesses and are a barrier to recognising illness and recovery [13–15]. There is a distinction between strength – to carry on regardless, and courage – to admit ones’ vulnerability – which is key to overcoming shame. Doctors who are at risk of burnout tend to feel shame acutely, deny their vulnerability and score very low on self-compassion [16].

The importance of group dynamics was bought up by Julian Lousada in the third keynote and was a recurrent theme. Bad organisations tend to scapegoat and locate their problems in an individual. We should ask ourselves, ‘what kinds of organisations have whistleblowers?’ There is a growing, if nascent interest in ‘enabling environments’ creating the organisational culture in which professionalism and resilience can flourish. One of the most important things organisations can do, and another strong theme from the conference, was to enable members to tell their stories. Accountability, according to safety expert Sidney Dekker, is to give accounts and a ‘just culture’ is one in which accounts are freely given and heard without blame [17]. If you want to understand terms like burnout and resilience, listening to stories told by those who have experienced it will teach you far more than turning to a dictionary or Wikipedia. Sharing stories and having our stories really heard is one of the most important ways we can prevent burnout and nurture resilience.

Relationship-centred care

As the conference drew to a close I found myself sitting next to Pip Hardy from Patient Voices http://www.patientvoices.org.uk/ an organisation that uses video, audio, still images and music to convey patients’, carers’ and practitioners’ own stories in a unique way. I had just seen a headline on the BBC that the new junior doctors’ contract would put patients first. ‘Putting patients first’ is a powerful rhetorical statement that carries the assumption that someone (junior doctors?) or something (the NHS?) is not putting patients first. The rhetoric serves a political purpose which is to undermine public confidence in the institution of the NHS, which is necessary if it is to be dismantled and privatised. The government will deny this intention at the same time as they portray healthcare professionals as being opposed to the interests of patients as, for example, they push for routine, 7 day services. The Francis report into failings of care at Mid Staffordshire hospital made it clear that the focus on patients was being lost because of the demands of financial control and inspections. Throughout the NHS the dead weight of market bureaucracy; finance, inspections, regulation, contracts and commissioning -imposed by government, not health care professionals – has put considerations other than patients to the fore. Government is to blame for this, not healthcare professionals.

What Pip and I concluded was that we could counter the divisive rhetoric if we could find ways to share patient, carer and professional narratives to show how intertwined and interdependent and complex healthcare can be. In his review of a book written by a doctor, Arthur Kleinman wrote of the need for writing that centres on the moral and emotional exchange in the doctor-patient relationship [18]. I sincerely hope that we have time to facilitate this. A mutual appreciation of the experiences of care can support resilience; a study of resilient GPs working in challenging, deprived areas found that they were sustained by a deep appreciation and respect for the population they served [19].

In conclusion

The conference concluded with Jon Ballatt and Penny Campling – the husband and wife team who wrote the wonderful book, Intelligent Kindness [20]. When healthcare professionals are treated with kindness and compassion, when they have sufficient resources, support and control over their work, then patients benefit and if not, patients suffer.

The problem with resilience. Excellent blog from retired psychiatrist Linda Gask criticising an over-emphasis on individual resilience

Doctors need to be supported, not trained in resilience. Important piece in the BMJ highlighting the lack of evidence for resilience training.

For more on The Paradox of the Wounded Healer, I recommend this essay by David Zigmond

My related blogs:

The Wounded Healers

The Emotional Labour of Care

When Doctors become Patients

References: 

1            Maben J, Latter S, Clark JM. The sustainability of ideals, values and the nursing mandate: evidence from a longitudinal qualitative study. Nurs Inq 2007;14:99–113. doi:10.1111/j.1440-1800.2007.00357.x

2            Cole-King A, Gilbert P. Compassionate Care: The theory and the reality. J Holist Healthc 2011;8:29–37.http://www.connectingwithpeople.org/sites/default/files/Compassionate care ACK and PG.pdf

3            Tomlinson J. Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Med Educ 2015;15:103. doi:10.1186/s12909-015-0324-3

4            Carel H, Kidd IJ. Epistemic injustice in healthcare: a philosophial analysis. Med Health Care Philos Published Online First: 17 April 2014. doi:10.1007/s11019-014-9560-2

5            Point of Care Foundation. Point of Care Foundation – Schwartz Rounds. 2013.http://www.pointofcarefoundation.org.uk/Schwartz-Rounds/ (accessed 20 Oct2014).

6            Theodosius C. Emotional Labour in Health Care: The Unmanaged Heart of Nursing. 1st ed. Routledge 2008. http://books.google.com/books?hl=en&lr=&id=g4xPOKWTX2sC&pgis=1 (accessed 11 Aug2014).

7            Newman MC. The emotional impact of mistakes on family physicians. Arch Fam Med 1996;5:71–5.http://www.ncbi.nlm.nih.gov/pubmed/8601210 (accessed 7 Aug2014).

8            Luu S, Patel P, St-Martin L, et al. Waking up the next morning: surgeons’ emotional reactions to adverse events. Med Educ 2012;46:1179–88. doi:10.1111/medu.12058

9            Caldwell G. The RCPE response to Mid Staffordshire. J R Coll Physicians Edinb 2013;43:188–9. doi:10.4997/JRCPE.2013.222

10          Launer J. Power and powerlessness. Postgrad Med J 2009;85:280–280. doi:10.1136/pgmj.2009.081885

11          Zenasni F, Boujut E, Woerner A, et al. Burnout and empathy in primary care: three hypotheses. Br J Gen Pract 2012;62:346–7. doi:10.3399/bjgp12X652193

12          Zigmond D. Doctors have always been over-worked, but that’s not what’s causing the recruitment crisis. OpenDemocracy. 2015.https://www.opendemocracy.net/ournhs/david-zigmond/doctors-have-always-been-overworked-so-what-really-lies-behind-recruitment-cris (accessed 16 Sep2015).

13          Tomlinson J. BMJ Careers – Lessons from ‘the other side’: teaching and learning from doctors’ illness narratives. BMJ Careers. 2014.http://careers.bmj.com/careers/advice/view-article.html?id=20017843 (accessed 19 Jan2015).

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16          De Zulueta PC. Suffering, compassion and ‘doing good medical ethics’. J Med Ethics 2015;41:87–90. doi:10.1136/medethics-2014-102355

17          Dekker PS. Just Culture: Balancing Safety and Accountability. Ashgate Publishing, Ltd. 2012. http://books.google.com/books?hl=en&lr=&id=hntr2Ok3Ed0C&pgis=1 (accessed 7 Aug2014).

18          Kleinman A. Medical sensibility: whose feelings count? Lancet 2013;381:1893–4. doi:10.1016/S0140-6736(13)61146-0

19         Stevenson AD, Phillips CB, Anderson KJ. Resilience among doctors who work in challenging areas: a qualitative study. Br J Gen Pract 2011;61:e404–10. doi:10.3399/bjgp11X583182

20          Heath I. Kindness in healthcare: what goes around. BMJ 2012;344:e1171–e1171. doi:10.1136/bmj.e1171