Recent tweets by the police have been interesting, claiming that it is PTSD – recognised or not – following the witnessing of some pretty horrendous scenes that causes burnout over a period of time. Similarly in medicine some people believe that being party to clinical trauma and complex injury, end of life care and random ill health, especially in children and young people can also lead to burnout. Whilst this may well be true – and is not disputed here, there are other reasons given for burnout in healthcare professionals.
In May 2019, Liz Crowe, a Wellbeing specialist as well as a Critical Care clinician, tweeted a list of contributory factors including: feeling devalued; feeling squashed by the system; a lack of acknowledgement of excellence and commitment of individuals; the role of bureaucracy; a disconnect between systems and patient care; terrible rotas and a lack of flexibility in the system.
According to Liz it is not the clinical trauma we see and attempt to ameliorate, that causes our burnout, but the inhumanity of the system which employs us. What is interesting about this system is that it extends beyond our hospitals, so the same inhuman expectations, the same behind-closed-doors whispers also take place in organisations affiliated with the healthcare system but not directly funded by it, such as the Royal Colleges, the Medical Schools and the ancillary organisations such as professional associations.
Whilst we do not disagree with Liz, we would go further to identify the root cause of burnout.
For us it is about the cognitive dissonance which exists in healthcare. For many years healthcare professionals: doctors; nurses; radiographers; therapists; scientists and all the other support staff enter this world wanting to and believing they can help patients. They train and practise with their guiding values being those that help others, support a greater good, are compassionate, often altruistic and which accord with their own values. I have never met a healthcare employee who does not want to make a difference for patients experiencing their most difficult times. For some this takes years to achieve. They are trained to care and they want to care. Why would anyone work in a materially shabby environment – most GP surgeries and hospitals are falling down in the UK – for any other reason? The pay is not great, the conditions are last century and the public are demanding to say the least. And yet Care is what the do. They care for and they care about.
But, and here is the reason for the burnout, they are not allowed to care. Once they are into their careers, they uncover the conspiracy of the healthcare system, which is that it is not about helping and caring; it is about money. And it is seriously underfunded. It’s transactional, not transformational.
Often healthcare professionals are prevented from caring, prevented from doing what is best for their patients through a lack of resources, which is political or a form of organisational management which privileges one patient over another. Being prevented from doing what you have dedicated your life to do causes huge emotional turmoil. How do we square that with our consciences, with our identities? I am a carer but today I was not able to care.
Even worse is the pressure to keep quiet about not being able to care. Every time a clinician is asked to keep quiet about an injustice, a prevented care opportunity, an error in resourcing, they go home wracked with guilt about their complicity in the system. And clinicians are not alone in this. How many managers also feel the duplicity of their roles? How often are they asked to silence a colleague – clinician or otherwise? How often do they pour a glass of alcohol once home, to subdue the feeling that their lack of response to that email is part of a greater conspiracy?
To uphold the culture of complicity within this business mindset creates huge cognitive and emotional dissonance for all who work in healthcare.
Not being able to do your job must be one of the biggest traumas we can face. Nobody enters healthcare lightly. People’s continuing contribution is often made with some sacrifice. We know that self efficacy, being able to achieve what we want to achieve, is a major driver for all of us. So what happens when we are not able to do what we have trained to do, for many years; are prevented from helping the people we have chosen and made sacrifices to help?
We either fight the system, which in many of our healthcare cultures is either professional suicide or a lengthy, and costly process which many who have done so would not, given their new knowledge, choose to do again. Or we internalise the grief.
And that, we suggest, is called burnout. No wonder it is rife.