EJD Policy on burnout and psychosocial wellbeing

0 – Introduction

Over the course of the last decades increasing attention has been paid to the psychosocial wellbeing of Junior Doctors and other health and care professionals. The latest systematic reviews and metanalyses show that the estimated prevalence of depression and depressive symptoms among Junior Doctors was 28,3% (1) and the burnout prevalence has remained stable over the last two decades at an alarming 47,3% rate (2). Physicians have higher suicide mortality rates than the general population, particularly female physicians (3).

Furthermore, the COVID-19 pandemic has taken a significant toll on the already distressed mental health of Junior Doctors. The psychosocial wellbeing of this group is inextricably linked to the working conditions of the healthcare systems in which they work: long working hours, shift-work, unpredictable hours and nightshifts, noncompliance with working time regulations, considerable workloads, absence of breaks and resting facilities, low participation in decision-making, lack of control over workload, institutional violence and increased mobbing, role ambiguity and a vulnerable position in the workplace hierarchy, inadequate remuneration, work-life imbalance, to name only a few. All these factors are well known psychosocial risks deleterious to the mental health of workers (4). When risk factors accumulate, they can lead to occupational phenomena such as burnout, moral injury, and compassion fatigue which, in turn, increases the possibility of developing mental health conditions.

In a time of scarcity of doctors and other health professionals in Europe it becomes imperative to address the psychosocial wellbeing of junior doctors not only as a measure of justice and recognition of the efforts and sacrifices which occurred during the pandemic, but as a way of ensuring adequate working conditions which can prevent a further deterioration of the mental health of the workforce. In the words of the WHO’s framework on the health and care workforce 2023-2030: it is Time to Act (5).

1 – What is burnout?

According to the International Classification of Diseases (ICD-11) (6) burnout is an occupational phenomenon conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:

• Feelings of energy depletion or exhaustion. A worker who suffers from burnout can have feelings of overstrain, tiredness, and fatigue, which result from long-term involvement in an over-demanding work situation.
• Increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; this reflects an indifferent and distant attitude towards work, disengagement, and a lack of enthusiasm for work. It is a dysfunctional way of coping with exhausting situations, reducing the possibilities of finding creative solutions at work.
• Reduced professional efficacy. Professional efficacy consists of feelings of competence, successful achievement, and accomplishment in one's work, which diminishes as burnout develops.

Burnout refers specifically to phenomena that takes place in the occupational context and has been widely studied in healthcare, specifically in physicians. In recent years, there has been a heated debate around concepts which try to address workplace related suffering and unrest. In this sense, burnout has been challenged as a concept which restricts occupational problems to the individual and which shadows the role of healthcare systems and institutions. Consequently, some authors have claimed that moral injury and compassion fatigue could better explain doctor’s complaints.

On the one hand, moral injury refers to the psychological and emotional distress that occurs when a person's moral or ethical beliefs are compromised. In healthcare, moral injury can result from situations where physicians feel they are unable to provide the care they believe their patients need due to external constraints, such as limited resources or institutional policies. This can lead to feelings of guilt, shame, and betrayal (7). On the other hand, compassion fatigue refers to the emotional exhaustion that can result from caring for others who are suffering; it can be caused by exposure to high levels of stress, trauma, and suffering (8)

Some authors argue that all these concepts could be considered as different facets of the harm a worker could suffer when faced with different occupational psychosocial hazards and could represent a continuum rather than being distinct entities. In this sense it is important to highlight that burnout, moral injury and compassion fatigue act as psychosocial risks which make the doctor more vulnerable to different health problems (9).

2 – Why is it important to address?

Addressing burnout in junior doctors is crucial for multiple reasons:

• Firstly burnout is problematic in and of itself, with feelings of energy depletion, distance from one’s job, and reduced professional efficacy. All these negatively impact the wellbeing and mental health of doctors.
• Secondly, studies have shown that burnout is associated with an increased risk of depression, anxiety, and substance abuse among healthcare professionals. A previous survey described that 33% of physicians reported excessive fatigue, 11% reported a significant medical error in the previous 3 months and 7% reported recent suicidal ideation (10) If left unaddressed, burnout can significantly affect the quality of life of junior doctors, which can in turn impact the quality of care they provide to their patients (11).
• Thirdly, burnout in junior doctors can also have serious implications for patient care. Burnt-out doctors are more likely to make medical errors, with 9-11% of doctors reporting a major medical error in the previous 3 months (12) Additionally, they have lower job satisfaction, and report lower levels of empathy towards their patients. These factors can ultimately affect the quality of care provided to patients, potentially leading to adverse outcomes. It can also lead to premature departure from their organization, which is associated with increased costs in replacing and training new doctors, reduced productivity, and lower quality of care (13)

Addressing burnout in junior doctors is therefore essential not just for the wellbeing of physicians themselves, but also for ensuring that patients receive optimal and safe care. By prioritizing the prevention and management of burnout, healthcare organizations can help to create a more sustainable and supportive working environment for their junior doctors, ultimately benefiting both doctors and patients alike (14-15).

3 – Recommendations

All governments and administrations must recognize the exceptionally vulnerable position of Junior Doctors in the healthcare system, and take responsibility of their psychosocial wellbeing.

To this aim it is important to develop indicators and gather information about the psychosocial risk at the level of the country, the region, the institution, and the training program. Administrators and staff should have specific training on improving occupational wellbeing.

There is no one size fits all solution. In order to protect the mental health of junior doctors, it is vital to implement systemic multi-layer interventions directed at how healthcare is provided, ensuring optimal training capacities, implementing cultural and institutional changes and providing resources to individuals.

General Recommendations:

• The most effective interventions are the ones which aim to improve junior doctors’ working conditions (primary prevention):
  • Address the underlying issues of chronic staff shortages and workload pressures that impact the wellbeing of doctors. Healthcare institutions which do not have sufficient staffing levels should not be accredited to deliver PGT.
  • Junior Doctors should have appropriate workloads (avoiding over and underloads) which ensure the attainment of PGT outcomes. Healthcare institutions which do not have sufficient staffing levels should not be accredited to deliver PGT.
  • Working time regulations must be respected and junior doctors should not surpass the European Working Time Directive’s standards (or that country’s standards in the case those are more protective than the directive). Daily and weekly rests as well as annual leave and study leave need to be ensured.
  • Shifts and rostering should be flexible and ensure work-life balance, particularly in cases where physicians have caregiving responsibilities. Flexible working schemes should be available and promoted when needed.
  • Institutions will provide with adequate resting facilities and ensure breaks during shifts. Encouraging breaks and providing spaces to rest can help increase efficiency and productivity while also helping to avoid burnout. Fatigue management strategies should be implemented at the level of the department and take into account vulnerable workers.
  • Institutional violence prevention strategies and protocols should be developed. In this regard they should not only consider patient violence (verbal or physical) but mobbing and sexual assault by peers and/or senior staff.
  • Reducing paperwork and the administrative workload can also help to reduce burnout and improve work-life balance. This can be achieved with on-going investment and development of eHealth including investment in electronic health records.
  • Adequate equipment should be readily available in cases of risk of infection (PPE), radiological risk and other potential environmental hazards.

Recommendations at departmental and institutional levels:

• Organizational interventions that address psychosocial risk factors, including interventions involving participatory approaches should be incentivized to reduce emotional distress and improve work-related outcomes.
• Clear policies and procedures must be in place to ensure all healthcare professionals feel able to take breaks and to take time off when ill. Institution should accommodate for the needs and implement strategies directed at vulnerable junior doctors including those with mental health conditions and psychosocial disabilities, in line with international human rights principles.
• Senior staff and managers should have specific and adequate training to support their workers’ mental health and which could improve their knowledge, attitudes, and behaviors in this area.
• Mental health literacy and awareness should be part of the PGT core curriculum to improve trainees’ mental health-related knowledge and attitudes at work, including stigmatizing attitudes.
• Raise awareness of mental health issues and burnout among the medical profession to address the high levels of stigma and to encourage help-seeking and the use of support services.
• Institutions should consider creating the role of the wellbeing officer to coordinate the efforts, protocols, and strategies in place.
• Team facilitated discussions and peer support initiatives should be incentivized (Critical incidents model, Schwartz rounds, Balint groups, etc.)
• Institutions should be aware of the risk-factors and protective factors of psychosocial stress according to recent evidence (13). Whereas autonomy and jobsatisfaction are important protective factors that should be taken into account. Therefore autonomy of doctors in the workplace should be encouraged.

Recommendations at the individual level:

• Access to specialized mental health services should be encouraged and made available for workers who need it, bearing in mind that this would constitute a tertiary intervention and not a first-line intervention.
• Isolated individual interventions should be avoided because they could potentially transfer the responsibility to the junior doctor and become stigmatizing and consequently could promote the phenomena of dissatisfaction and burnout further.
• Individual interventions like physical activity, mindfulness, relaxation techniques and other therapies have demonstrated to be helpful. Institutions should offer guidance and training on voluntary basis.
• Encourage all Doctors to have their own Family Doctor / GP

4 – References

1. Naji L, Singh B, Shah A, Naji F, Dennis B, Kavanagh O, Banfield L, Alyass A, Razak F, Samaan Z, Profetto J, Thabane L, Sohani ZN. Global prevalence of burnout among postgraduate medical trainees: a systematic review and meta-regression. CMAJ Open. 2021 Mar 8;9(1):E189-E200. doi: 10.9778/cmajo.20200068. PMID: 33688027; PMCID: PMC8034324.
2. Mata DA, Ramos MA, Bansal N, et al. Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis. JAMA. 2015;314(22):2373–2383. doi:10.1001/jama.2015.15845
3. Dutheil F, Aubert C, Pereira B, Dambrun M, Moustafa F, Mermillod M, Baker JS, Trousselard M, Lesage FX, Navel V. Suicide among physicians and health-care workers: A systematic review and meta-analysis. PLoS One. 2019 Dec 12;14(12):e0226361. doi: 10.1371/journal.pone.0226361. PMID: 31830138; PMCID: PMC6907772.
4. World Health Organization (2022). WHO guidelines on mental health at work. Geneva. Licence: CC BY-NC-SA 3.0 IGO.
5. World Health Organization (2023). WHO European framework for action on the health and care workforce 2023-2030.
6. World Health Organization. (2019). International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/
7. Dean W, Talbot S, Dean A. Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract. 2019 Sep;36(9):400-402. Erratum in: Fed Pract. 2019 Oct;36(10):447. PMID: 31571807; PMCID: PMC6752815.
8. Shane Sinclair, Shelley Raffin-Bouchal, Lorraine Venturato, Jane Mijovic-Kondejewski, Lorraine Smith-MacDonald, Compassion fatigue: A meta-narrative review of the healthcare literature, International Journal of Nursing Studies, Volume 69, 2017, Pages 9-24, ISSN 0020-7489, https://doi.org/10.1016/j.ijnurstu.2017.01.003.
9. Rosen A, Cahill JM, Dugdale LS. Moral Injury in Health Care: Identification and Repair in the COVID19 Era. J Gen Intern Med. 2022 Nov;37(14):3739-3743. doi: 10.1007/s11606-022-07761-5. Epub 2022 Aug 15. PMID: 35970958; PMCID: PMC9377663.
10. Tawfik DS, Profit J, Morgenthaler TI, Satele DV, Sinsky CA, Dyrbye LN, Tutty MA, West CP, Shanafelt TD. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clin Proc. 2018 Nov;93(11):1571-1580. doi: 10.1016/j.mayocp.2018.05.014. Epub 2018 Jul 9. PMID: 30001832; PMCID: PMC6258067.
11. Patel, R. S., Bachu, R., Adikey, A., Malik, M., & Shah, M. (2018). Factors Related to Physician Burnout and Its Consequences: A Review. Behavioral sciences (Basel, Switzerland), 8(11), 98. https://doi.org/10.3390/bs8110098
12. Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Healthcare Professionals: A Call for Action. Crit Care Med. 2016 Jul;44(7):1414-21. doi: 10.1097/CCM.0000000000001885. PMID: 27309157.
13. Pélissier C, Charbotel B, Fassier JB, Fort E, Fontana L. Nurses' Occupational and Medical Risks Factors of Leaving the Profession in Nursing Homes. Int J Environ Res Public Health. 2018 Aug 27;15(9):1850. doi: 10.3390/ijerph15091850. PMID: 30150568; PMCID: PMC6163261.
14. Dewa, C. S., Loong, D., Bonato, S., Trojanowski, L., & Rea, M. (2017). The relationship between resident burnout and safety-related and acceptability-related quality of healthcare: a systematic literature review. BMC medical education, 17(1), 195. https://doi.org/10.1186/s12909-017- 1040-y`
15. Hall, L. H., Johnson, J., Watt, I., Tsipa, A., & O'Connor, D. B. (2016). Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PloS one, 11(7), e0159015. https://doi.org/10.1371/journal.pone.0159015 10