Graham Russell with a key theme from his new book, 'Understanding Vulnerability and Resilience: A Guide for Professionals who work with Vulnerable Others'.
31 March 2023
In 2021, the UK's Health and Safety Executive reported that stress, alongside anxiety and depression, has become one of the leading causes of sickness in the UK workforce. This is reflected in a wide range of studies that have documented high levels of stress in doctors, social workers, teachers and prison staff.
Dr Paula McFadden, for example, from the Queen's University Belfast Centre of Evidence and Social Innovation, found that one in three UK social workers had symptoms of emotional exhaustion as assessed by the Maslach Burnout inventory. The UK's General Medical Council recently reported that one in four UK doctors felt burnt-out due to a high or chronically excessive workload with one in the three General Practitioners at risk of burnout. Professor Gail Kinman from Birkbeck University of London found that prison staff had relatively high levels of self-reported stress and burnout and GOV.UK reported high rates of attrition in teachers that were associated with stress, high workloads and a poor work-life balance. Likewise, in a recent article in the The Guardian, the incoming WHO chief scientist, Professor Jeremy Farrar warned that the situation in healthcare was so serious, that burnt-out health workers across the globe simply do not have the resilient reserve to deal with another major epidemic.
What is stress and burnout?
Stress in itself is not a bad thing. Transient stress, for example, is normal, and a modicum of apprehension can be advantageous when we find ourselves confronted with challenging situations. For an A&E consultant gearing herself up to deal with multiple, serious injuries relating to a major road traffic accident, the release of stress hormones is beneficial, because they will boost blood sugar and sharpen the ability to make rapid decisions, which can be vital in saving lives. Moreover, the stress that she experiences will quickly subside when the patients have been triaged and treated and she is afforded the opportunity to recover and relax at home.
In the latter scenario, the stress that the consultant experienced was short-lived and there were no lasting effects. Chronic stress, however, is a very different animal, because it tends to be debilitating and pervasive. Of particular interest here is the rise in cases of burnout, a complex and insidious form of chronic occupational stress, which is currently endemic in professions where staff have high levels of engagement with vulnerable adults or children who have complex needs.
Burnout is not like simple, transient stress. It is a complex, debilitating disorder that results from chronic exposure to occupational overload and it degrades and impairs just about every aspect of normal human functioning. Evidence, for example, suggests that repeated exposure to high levels of stress over time can fundamentally alter the body's capacity for responding to stressful situations. The emotional processing centres in the mid-brain called the amygdala and hippocampus that are responsible for attenuating the normal (adaptive) stress response become impaired so the stress response cannot be switched off. This results in a state of hypersensitivity to stressors, and the body is repeatedly flooded with stress hormones known as glucocorticoids. The chronic release of these stress hormones is believed to affect the frontal lobes of the brain that govern attention, memory and judgement, leading to impairment in key cognitive functions, such as decision-making and the ability to focus on complex tasks. Should our A&E consultant be repeatedly exposed to repeated high levels of stress without sufficient opportunity to recover, she would start to find herself feeling overwhelmed by routine events and increasingly unable to relax and regenerate at the end of a shift. Indeed, at the time of writing this article, researchers at Leeds University had just published the results of a study which suggests that exposure to unremitting stress associated with long-working hours and understaffing is fuelling widespread, early symptoms of burnout in junior doctors.
In documenting the effects on the body of persistent exposure to stress, neuroendocrinologist, Robert Sapolsky, in his 2004 book Why Zebras Don't Get Ulcers, explains that the body's hormonal systems have essentially evolved to deal with short-term stressors and animal studies have shown that exposure to chronic, unremitting stress leads to the depletion of key stress hormone, such as cortisol, with the result that the body becomes unable to mount an effective response to potentially stressful situations. If this continues unabated the body reaches a point where it literally runs out of fuel. At this point, our consultant in A&E would feel physically and emotionally exhausted. She would be unable to muster the attentional processes necessary to deal with complex situations nor would she be able to recover at the end of a shift.
These processes do not occur overnight. Psychologist Christine Meinhardt states that it takes five to ten years to reach the point where emotional and physical exhaustion have become so profound that the individual lapses into a state of depression and agitated helplessness. To make matters worse, the accompanying feelings of powerlessness and helplessness contribute to a negative feedback loop as feelings of shame, guilt and self-insufficiency act to further exacerbate chronic feelings of stress.
The causes of burnout
As noted, burnout is closely associated with exposure to unremitting occupational stress that consistently places too much of a burden on employees over long, protracted periods of time. This is problematic because there are finite limits to what we humans can endure. Everyone (regardless of experience and training) is at risk of succumbing to burnout if exposed to factors such as constant physical exhaustion, insomnia and emotional overload. There are only so many times that our emergency doctor can cope with multiple serious injuries without regular opportunities to recoup and regenerate their physical and emotional batteries.
Elaborating on this point, Danish psychologist Robert Karasek has proposed that burnout occurs when people find themselves faced with occupational demands that consistently exceed their capacity to cope, with the risk of burnout increasing as a function of incongruity between the two factors. This position reflects modern stress theory – the greater the perceived discrepancy between capacity and demand, the higher the experienced levels of stress.
However, many other factors have been identified in the aetiology of burnout. Swiss psychologist Veronika Brandstätter, for example, states that research has shown that employees are prone to burnout when the reality of working on the ground consistently fails to match their values and ideals. A common source of stress for nurses, for example, is anxiety linked to the inability to provide safe and compassionate levels of patient care. Similarly, social workers experience stress when high caseloads result in their having to prioritise clients who are all deemed to be at risk. Likewise, burnout has been found to be associated with lack of job-congruence in idealistically motivated aid workers, who find themselves overwhelmed and impotent in the face of wide scale human misery, caused by factors, such as man-made catastrophes and poverty associated with state-sponsored corruption.
In a similar vein, burnout has been linked with job-incongruence and frustration flowing from bureaucratic tasks that seem to violate staff's professional integrity. Nurses in Denmark, for example, frequent complain that opportunities for direct patient contact are hampered by the inordinate amount of time that is required to complete IT-based quality assurance tasks. Various studies have shown that professionals in fields like health, social work and teaching regularly experience frustration relating to high levels of 'policy churn' as incoming government ministers seek to establish themselves.
Likewise, burnout is more likely to occur when employee's experience a sense of injustice that reflects a fundamental imbalance between perceived personal efforts and rewards, or when employees feel they have little control over the tasks that they perform or the environments that they inhabit.
Why burnout is a problem for organisations
The human costs of burnout are serious and well-documented. Sapolsky, for example, states that chronic stress is widely associated with a range of long-term health conditions, including heart disease and auto-immune disorders like fibromyalgia. In addition, burnout takes an immense emotional toll resulting in depression and complex, negative changes in self-perception in victims that are pervasive and difficult to resolve.
However, employee burnout is also a serious issue for organisations, and particularly with regard to long term sickness, staff attrition and recruitment. Numerous studies have shown that burnout is highly prevalent in health, social care, teaching and the prison services, and it goes without saying that sick employees do not make for efficient employees. Deficits in key areas of executive functioning like memory attention and decision-making invariably impact on the quality-of-service provision and emotional blunting can rob staff of their capacity to be compassionate and caring.
Moreover, as Meinhardt notes, whilst early-stage (simple) stress is readily amenable to standard psychological interventions, chronic burnout is complex and difficult to treat and invariably associated with long term sickness and staff attrition. This can prove a serious issue for organisations and their patients or clients, particularly when novice, inexperienced staff are left to deal with complex cases without sufficient levels of expert guidance and supervision. The consequences of this can be tragic. Following the recent murder of law graduate Zara Aleena, for example, the chief inspector of probation Justin Russell, established that a pattern of systemic failures could be traced back to heavy personal workloads and high staff vacancy rates, which had resulted in a lack of experienced staff to mentor and support young probation officers who were dealing with complex cases.
Burnout can also have a direct impact on the quality and care and support that is offered to vulnerable others. Burnout is an emotionally painful condition and emotional blunting is a common way of coping with the pain of seeing oneself as failing. Staff who are burnt-out often have difficultly feeling empathy for others and compassion may be replaced by actions that are conducted on autopilot. At best burnout sufferers may mechanically say and do the right thing (referred to as 'presenteeism'), and at worst may show a seemingly cynical disregard for those who are in their care. Such effects were noted in the Francis Enquiry which was established to report on the causes of widespread, serious failures in patient care at the Mid Staffordshire NHS Trust and in the Ockenden Enquiry, which examined comprehensive failures of care in midwifery services at the Shrewsbury and Telford Hospital Trust. In addition, anecdotal evidence suggests that high levels of staff sickness, attrition, failures of care and the scapegoating of staff make organisations less attractive to potential employees, which may well be a contributing factor in the global recruitment crises that is affecting organisations in health, social care in the UK and many other European countries.
What can be done to reduce staff burnout (and increase organisational resilience)?
We have clearly reached the point where action needs to be taken to address the problem of endemic burnout. Business as usual is not viable option, and it is incumbent upon organisations to recognise and accept that there are finite limits on what staff can endure physically and emotionally without succumbing to the pervasive effects of chronic stress.
However, viewed from a historical perspective, efforts to improve the efficiency of public sector organisations like the NHS have focused primarily on productivity and the resulting policy drivers have generally been designed to squeeze staff in order to get more for less. This, according to David Maguire, a senior analyst at the King's Fund, has become untenable in light of current levels of staff sickness and attrition relating to stress. Sustainable gains in organisational efficiency, he argues, must come from identifying ways of increasing the quality and provision of systems and human resources that exist to support staff rather than simply doubling down on efforts to reduce costs, whilst simultaneously seeking to boost outputs.
In a report for the Department of Health in 2016, for example, Lord Carter of Coles proposed that the NHS should work to identify the causes of stress sickness and attrition to improve the quality of the working environment, so as to ensure that staff are motivated to return to work. These themes are also mirrored in the NHS People Plan, which emphasises the importance of developing compassionate and inclusive cultures and practices where staff's inputs are recognised and rewarded together with flexible and support for staff with domestic caring roles and other such responsibilities.
Despite this, the tools signposted in the recent NHS Value and Efficiency Map focus almost exclusively on financial and economic factors relating to productivity. They neglect to draw attention to the importance of staff well-being as the pivotal factor in organisational efficiency. Indeed, to reiterate an early point, one of the key drivers of burnout is the existence of a chronic imbalance between the situational demands and the capacity of individuals (or teams) to cope. Moreover, it is evident that staff's ability cope with stress is strongly mediated by the quality the occupational and social environments that they inhabit, rather than the quality of their personality traits.
This is an important and often overlooked point. We possess a strong, unconscious tendency to assume that human vulnerability and resilience are best characterised as personality traits that reside within certain individuals. We readily embrace the idea that some people are 'born leaders' because they possess qualities like 'grit and determination', and we conversely assume that people who succumb to conditions like stress must somehow be lacking in these same qualities. In doing so, we deny the fact that vulnerability is a Condition Humana that renders each and every one of us susceptible to the effects of prolonged stress. Uber-resilience exists only in the stuff of Hollywood fiction, and it is evident that personal resilience in the workplace is highly dependent upon situational factors, such as perceived control and autonomy, a good balance between demand and capacity, effective support and congruence between personal goals and the reality of what can be achieved on the ground.
In addition, we need to consider the issue of how we commonly make sense of failure in organisations. When vulnerability is regarded as residing within the individual rather than organisational systems and contextual factors (such as high levels of staff-attrition and policy drivers that seek to maximise economic efficiency), the organisational response to failure is often to reflexively point the finger at individuals, who are assumed to be weak and ineffective, rather than resilient and powerful.
A classic example of this can be found in the scapegoating and unfair dismissal of Sharon Shoesmith, the former Haringey children's service's boss, who carried the can for global, systemic problems over which she had limited control. Indeed, although it is well known that tragic events often arise from failures of service provision associated with factors, such as high levels of long-term staff sickness and staff attrition, it is often legally safer and less embarrassing for organisations to pin the blame on individuals rather than open the door to an examination of issues that might reflect badly on senior managers.
Such problems are found in all areas of public service. It has been reported, for example, that Ofsted reports sometimes hold Heads of Schools personally responsible for their failure to attract and recruit teachers in core Stem subjects even though it is widely known that a national shortage has existed for decades. Not only do such practices lack common-sense and compassion, they are also self-defeating. Staff are left feeling demoralised and systemic, organisational problems remain unchallenged and unresolved.
Bright spots
However, there are bright spots on the horizon. The past decade has seen a burgeoning interest in the role of compassion in promoting resilience and well-being, and this has been extended to encompass occupational fields. The aforementioned NHS People Plan, for example, has drawn attention to the need for compassionate practices in management, but what is a compassionate organisation, and can it fruitfully coexist alongside hard-nosed economic and financial drivers?
Professor Paul Gilbert suggests that it can. A compassionate organisation may be defined as one that places staff well-being at the centre of its policies and practices. Indeed, acts of compassion have been shown to promote personal well-being, reduce stress and depression and are associated with a protective sense of group-affiliation and belonging. Moreover, research has shown that personal resilience is strongly associated with a sense of community and shared values. Burnout, for example, has been found to be quite rare in communities where there is a strong sense of communion, social commitment and shared values. Collectivist cultures typically have lower rates of occupational burnout than cultures which prize individualism and competition.
Moreover, staff are happiest and healthiest when there is a good match between the aspirations and values that brought them into the workplace and the reality of what can be achieved on the ground. Conversely, burnout has been linked to perceived job-incongruence that occurs when work-related tasks consistently fail to meet staff's role expectations or when work practices violate staff's professional identity and integrity.
Working with large caseloads that jeopardise client safety are a major source of stress and job-incongruence. Likewise, tasks that are seemingly futile can conflict with core roles leading to stress and frustration, as was noted earlier in respect of Danish Nurses, who tend regard IT-based reporting systems as bureaucratic and counterproductive. Such problems have been found in schools too. A recent Portuguese study concluded that teaching staff often believed that school inspectors were more often concerned with identifying failure than good practice. Echoing this, Ofsted's own 2019 Teachers Attitude Survey reported that nearly one half of teachers viewed school inspections as a source of fear and stress associated with pointless box ticking tasks that were based on 'misguided priorities'.
In a similar vein, the Justice Theory of Burnout establishes a causal relationship between burnout and staff perceptions of fairness. According to a study conducted by Psychologist Nathaneal Campbell, for example, symptoms of emotional exhaustion, diminished personal accomplishment and staff commitment to the organisation where reduced when managers were perceived to treat staff fairly and displayed genuine concern, compassion and support for problems at work. Likewise, other researchers have found that the risk of burnout is reduced when staff perceive that organisational systems and structures promote professional freedom and autonomy, including the right to express professional opinion without fear of restrictive 'gagging clauses' that often function to 'hide' systemic problems and emerging issues.
To minimise burnout, it is imperative that organisations are transparent, and that functions relating to data-collection and other forms of quality assurance can be clearly seen to result in improvements in service provision and staff well-being. Not only does this approach, as public health researchers Veronica Toffolutti and David Stuckler have shown, result in lower patient mortality, it also reduces the stress that is associated with making mistakes and the associated fear of potential retribution. Various enlightened soles have long argued for such approach, including the academic surgeon and Peer of the Realm, Lord Darzi, who has argued that the NHS (and other public institutions) would benefit greatly from adopting the policies and practices found in the aviation industry where information about the reporting of error is mandated and globally disseminated.
According to Darzi, we need to accept the inevitability of human error that occurs in the context of complex work-related tasks and stressful environments, and it is incumbent upon organisations to understand and address the factors that are involved rather than castigate the individuals concerned. NHS England, for example, has recently called for the introduction of systems like those employed in the aviation industry to promote more openness and transparency so that staff feel better able to report mistakes which happen under pressure without fear of retribution.
Last, but not least, stress and the accompanying problems of long-term sickness and attrition can be minimised by establishing systems and procedures that promote early detection and treatment for burnout (i.e., indicators such as frequent sickness, emails that are regularly sent out at 2.00 am, etc). As previously noted, burnout often follows a chronic course and as Meinhardt states, it is much easier to prevent the development of chronic stress than it is to treat end-stage, burnout once self-denigration and exhaustion have set in.
Not only is such an approach sensible, compassionate, and morally correct. It is predicated on the principle that no organisation can hope to achieve enduring improvements in quality and efficiency without first ensuring that staff resilience and well-being are the central drivers in the formulation of policy and practice.
- Graham Russell is a retired, but professionally active Chartered Psychologist and Fellow of the Higher Education Academy. His new book Understanding Vulnerability and Resilience: A Guide for Professionals who work with Vulnerable Others is published by Routledge.
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