“It was hell,” says Sandy Buchman, president-elect of the Canadian Medical Association. “I was doing more and more with less and less support. I was burning the candle at both ends and was definitely burning out.”
Buchman has held more than a dozen regional and national leadership positions and won multiple awards. In 2004, he was named Family Physician of the Year for Southern Ontario. A year later, he was closing his comprehensive family medicine practice of more than 20 years, where he did everything from deliver babies to care for the dying in their homes.
“I had to do it,” he says, “for survival.” He had recently seen one of his colleagues end up in hospital after burning out, and felt he was headed there himself. Buchman transitioned to full-time palliative care at the Temmy Latner Centre, where he still works. He describes mixed feelings about the move: “I felt guilty for leaving my patients. I also felt like an impostor. I was the president of the Ontario College of Family Physicians and was no longer working as a family doctor.”
Themes from studies related to front-line health care providers are clear and grim: Burnout is common, as are mental health concerns and suicide, and their costs extend to patients and the system as a whole. In the U.S., these concerns recently culminated in a movement that proposes a holistic approach to health care wellness and engagement, known as “Joy in Work.”
Canadian professional associations and institutions are also turning their attention to the issue of provider wellness and engagement. Below, we present some Canadian context to the statistics and the theories proposed to explain them, describe two examples of interprofessional initiatives, and clarify what the current challenges are and what still needs to happen in order to best promote wellness among Canadian health care providers.
Joy and burnout in Canada
The Canadian Federation of Nursing Unions consistently reports depression rates among its members that are double those of the general population, with up to 40 percent of nurses suffering symptoms of post-traumatic stress disorder (PTSD). Similarly, according to the Canadian Medical Association 2017 National Physician Health Survey, 29 percent of working Canadian physicians report high levels of work-related emotional exhaustion, cynicism, and perceived reduced performance, the criteria used in 1974 to describe the syndrome of “burnout.” The survey further reports that 33 percent of Canadian doctors screen positive for depression, and nine percent have had suicidal thoughts in the past year.
Meanwhile, there is recent international evidence that the state of health care providers affects the quality of care they provide, and costs the system money through increased staff turnover and absenteeism. The quality-of-care and economic arguments for wellness have spurred institutions to take action, explains Shelly Dev, director of mentorship and wellness in critical care medicine at the University of Toronto. The majority of initiatives, however, have been focused on individual providers’ resiliency.
This focus is pragmatic, not evidence-based, says Gigi Osler, CMA president: “It is much easier to offer yoga than it is to change a system.” Studies from the Mayo clinic have suggested that solely addressing provider resiliency is less effective than targeting stressors at the organizational level, and may imply that the individual carries the brunt of responsibility for wellness in a dysfunctional system.
Coinciding with concerns about the validity of burnout and calls for a deeper understanding of provider health, the Institute for Healthcare Improvement (IHI) recently published a white paper that proposes a move from focusing on burnout to adopting “Joy in Work,” a concept originating in other industries. The IHI framework acknowledges individuals’ responsibility for monitoring their own wellness while emphasizing that leaders and institutions should support and promote provider engagement. The white paper suggests the addition of “Joy in Work” to the traditional IHI triple aim: better patient care, better population health, and lower costs.
While Canadian frameworks such as the Mental Health Commission of Canada’s National Standard and the Canadian Medical Association Physician Health Policy have contributed to the field of health care wellness and engagement, they have not been as comprehensive as the IHI. Nevertheless, most Canadian health care organizations are looking for ways to address provider wellness. Below we look at two Ontario examples.
Michael Garron Hospital: Asking for feedback and adding resources
In 2016, Michael Garron, a community hospital in Toronto’s southeast end, was recognized for its achievements in promoting employee health. It has since been named one of “Greater Toronto’s Top Employers,” and recently received the “2018 Mental Health at Work Order of Excellence.” Christine Devine, the hospital’s wellness specialist, and Ian Fraser, chief of staff, both feel these accolades are due to Michael Garron’s “flat organizational structure,” where employees have easy access to senior leadership. Whether through formal yearly engagement surveys, ad-hoc check-ins, or a mandatory daily safety check between senior leadership and managers of all clinical units, “we always start by asking [staff] what is important to them,” says Fraser. He puts it in IHI terminology: “What are the pebbles in your shoes?”
“When asked about factors affecting their engagement, people most commonly [answer]: ‘I don’t have enough time for my job and I don’t have enough resources for my job,’” says Devine. “If you don’t address operational and environmental [factors], you can do all the work you want on the emotional component—nothing is going to change.” To that end, MGH recently invested $1.35 million in 600 pieces of small equipment such as blood-pressure cuffs that communicate directly with the electronic health record (EHR), increasing time spent at the bedside rather than charting. In the last year, the hospital hired for 117 positions, 90 of them new (albeit partly due to an increase in the hospital’s number of beds).
Despite Michael Garron’s successes, the hospital’s long-term disability claims and the amount spent on medications for staff mental health conditions have increased. Fraser sees signs of these changes in his clinical work and front-line call, and agrees with Devine that the increased number, acuity, and complexity of patients, recent traumatic events such as the Danforth shooting, and the broader impacts of the opioid crisis may be factors in these rising numbers. Fraser also worries about the emotional cost of continuous improvement and openness about adverse events, particularly in the context of a professional culture that internalizes failure and has a hard time reaching out for help.
Still, both Devine and Fraser maintain that the trend in wellness is positive, and that they are committed to the organizational processes in place at MGH. “This is a journey for every organization in health care,” says Devine. “The work is never-ending in terms of communicating with staff and understanding what their challenges are and relating it back to patient care.”
SickKids: Expanding peer support
“Hey, something [just happened]. We’re working on it now. We may need some support later on.” This is one of the ways Kelly McNaughton, manager of the SickKids Peer Support and Trauma Program in Toronto, gets called in to work. A social worker by training, she has experience preventing traumatic stress in first responders in settings ranging from small-town fire halls to New York during the week of the 9/11 attacks.
A failed resuscitation of a young child, witnessed by their parents; the death of an adolescent who has been a hospital patient for a decade—such highly charged and emotional situations, McNaughton explains, often lead to providers experiencing doubts about their own competence, anxiety, and the “second victim” phenomenon. McNaughton leads debriefings, but the process relies heavily on peer support from SickKids staff who volunteer, are screened, and are trained to be counsellors to their colleagues. During debriefings, peers provide reassurance that a participant’s feelings are common and gently attempt to reframe their worries. They are also able to follow those who need to leave the room to provide one-on-one support and ensure safety. “We have had people breaking down in the hallway,” says McNaughton.
This is the second peer-support program that SickKids has implemented. The first, launched in 2011, did not last, says McNaughton, in part because of lack of integration with the hospital organizational structure. The current program, initially designed for one-on-one support, has expanded to include group debriefings, and has shown modest cost savings ($20,000). While the debriefing sessions are confidential, and clinical managers are not permitted to attend, McNaughton has noted that some of the aspects of the discussion, particularly with regards to more chronic stressors, such as electronic medical record implementation, may eventually be useful as feedback to management. McNaughton is currently compiling metrics on the first year of the program, and is optimistic that she will be able to advocate for more resources and expanded capacity—protected time for peer counsellors, for instance.
She is less optimistic about the culture she sees every day. “We miss [helping] staff who are over-performing. They perseverate on work, never go home, don’t do self-care, and don’t acknowledge their own need.” Staff feel guilty about taking time to debrief, McNaughton says. They believe stoicism is a requirement for good care and are concerned about career ramifications from sharing their feelings. The stigma associated with needing help is one of the main barriers to her work, she says.
The challenges of medical culture and reasons for optimism
“People allow their entire lives to unravel. They will stop exercising, they will lose friends, and their marriages will fall apart, but they will still come to work every day and give themselves up to it, even as they become less and less well.” Since speaking out in 2016 about her own early-career mental health struggles, Shelly Dev has heard similar stories from many colleagues. She, like Kelly McNaughton, is struck by how afraid people are to tell their stories: “These are highly successful individuals, but they still do not feel comfortable sharing their struggles for fear of being thought of as less competent.”
“There is a myth of the indefatigable provider,” says Chris Simpson, vice-dean of medicine and cardiologist at Queen’s University in Kingston, Ont. He describes a generation of physicians “who view abuse as the way to clinical excellence, and surviving it as a mark of nobility,” and adds his voice to worries expressed by Christine Devine and McNaughton about an educational system that exposes trainees to mid-career supervisors, “many of whom are unwell themselves.” On the other hand, he recognizes his own deep-seated awe when he interacts with colleagues who seem to be superhuman, and the insidious institutional policies that reward productivity at all costs.
Nadia Alam, president of the Ontario Medical Association, is concerned that the goals of the IHI framework will make providers who are already burned out feel like it is their responsibility to solve systemic health care problems. She also highlights the fact that in remote and Northern communities, the situation is more dire, and support is often lacking.
Everyone agrees that while there is no panacea, there is much to be hopeful about. In Ontario, provincial legislation has added nurses to the category of providers who no longer have to prove that a diagnosis of PTSD is related to their work. The topic of wellness and engagement has a permanent role in health care leadership circles. “The CEO of my hospital,” says Dev, “will tell me that [engagement] is his number one priority.” According to Gigi Osler, the CMA will be announcing a permanent vice-president of wellness position, as well as new initiatives in support of their Physician Health Policy in October, one day prior to the 2018 International Conference on Physician Health.
“I shouldn’t have had to leave family medicine,” says Buchman. “I was left to struggle to find a solution to my own burnout, and was lucky. If I could make people understand one thing, it’s that we are only human, and deserve humane working conditions.”
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It is, of course, commendable that the problem of excessive levels of “burn out”, depression, mental health and suicide among front-line healthcare workers are being addressed by (some, I suspect rather limited) initiatives to help those affected – and that “recent international evidence indicates (the very obvious, common-sense conclusion) “that … (this) … affects the quality of care”.
However, the initiatives outlined suggest that they are aimed at “alleviating the symptoms” rather than addressing the “disease” (and are diverting resources that might – in the absence of such “symptoms” – be used to improve patient care and safety): as Christine Devine’s quote in the article highlights – “if you don’t address operational and environmental factors … – nothing is going to change”; this is the “disease” – and it stems from a shortage of sufficient numbers of doctors, nurses and hospital beds (relative to the number of patients).
In Canada it is not that there are insufficient funds spent on healthcare. It is that the system is dysfunctional: according to international studies, it has resulted in Canada employing fewer doctors, nurses, hospital beds and diagnostic machines (per capita) than most comparable economies – while we also have among the highest (if not the highest) ratios of administrators to healthcare professionals and hospital beds in the World and are among the very highest spenders (per capita) on pharmaceuticals.
And, of course, this does have an effect on patient and caregiver well-being: extended wait times for a multitude of medical services often causes unnecessary stress and must, in some circumstances, have a deleterious effect on their condition (not to mention their satisfaction with the “service” they receive).
Well-run businesses know that their success depends on satisfied customers and (to make this possible) engaged staff – particularly those on “the front-line”.
Until those responsible for the direction and management of healthcare understand this need to address the “disease”, rather than treat the “symptoms” of it, the issues discussed in this article will continue to be perennial.
(I have a sense of futility about submitting this comment. The observations are so obvious and have been made countless times in innumerable ways but still fall on deaf ears – among those in a position to act upon them!)
Thank you for this comment.
This is how I feel, with no place to turn.
Healthcare has many challenges for it’s workers and I don’t see a light at the end of this tunnel in the near future.
This may become more challenging as the baby boomers ( a large portion of the workforce) start leaving the work sectors because there will be even more patients to care for.
This was an outstanding summary of the impact of burnout on the health care system.
As a Psychotherapist I made the decision to be in private practice a long time ago. After 30 years and at age 65, I continue to work learn and play in my job. I experience support, challenge and joy and bcontinue to provide others with the same.
My heart goes out to our healers in the medical professions. The most useful tool I use is the model of the Victim Triangle. As healers and teachers we need to dig deep and broad into our role as Rescuers. We need to heal our own Victimized and wounded selves before embarking on the road to a helping profession.
Yes indeed the medical system is broken. The larger societal field is broken. We need to acknowledge this and find our own pockets of support within the challenge.
Hi Emanuela Nardella –
Thank you for sharing, from your wisdom and from your heart
It will always be a challenge to work through the (Karpman) Triangle (I like to add the fourth position of negligent bystander to go with perpetrator, victim, and rescuer).
As the situation in the workplace becomes more taxing, and “victimized and wounded selves” or rescuing parts become more triggered, there will naturally be more perpetrator activity as well. And I think that this is the unspoken part that the article is missing. It’s very easy – in some ways – to say that the system is breaking us and burning us out. But it’s difficult to discuss the natural consequence that the same forces that drive breakdown also drive perpetration, which is what we’re seeing markedly in the breakdown of the larger societal field.
And the perpetration and negligent bystander stances lead to more animosity between patients and caregivers, and more toxic regulation, which just drives more extreme behavior within the Triangle. And when the organizations meant to protect and regulate are now traumatized and traumatizing, and locked into survival mode, where do we look for help?
You are right, I think, that we deal with our own trauma first alongside finding pockets of support … and perhaps the best hope is that those pockets become the source of vision and activism that can exist outside the “doer-and-done-to-world” where more and more organizations, caregivers and patients live.
Thank you Harry for expanding upon my comment. Absolutely the larger field with a macro lens defines us. How we relate, advocate, educate …within the larger field is part and parcel to our micro intra selves. Our intimacy blocks as the interpersonal angle is another impactful piece. Successful emotional/societal work is dependent upon raising awareness within all avenues.
Using the Co-Empowerment/Challenger/Supporter dynamic as a structure to ease movement away from the Victim/Persecuter/Rescuer Mentality by deconstructing our blocked fixed neurotic gestalts. We observe where in our experience the blocks are and use the empowerment model to create awareness, mobilization, action and assimilation of the new learnings.This is called the gestalt cycle of experience. It lights up the road to healing for us all.
Holland Bloorview Kids Rehabilitation Hospital was the first Canadian hospital to adopt Schwartz Rounds for compassionate care. Sunnybrook HSC followed about a year later. While not a cure for the systemic/organizational issues that give rise to provider burnout, Schwartz Rounds do address cultural tendencies to stoicism or not wanting to admit the emotional toll of the work of care and draws a direct line from compassion for self to compassionate caregiving.
We have two sessions on Joy in Work at the upcoming Quality Improvement and Patient Safety Forum and Health Quality Transformation held October 16-17 hosted by Health Quality Ontario
I appreciate the authors providing this piece that addresses the important issue of physician and nurse wellbeing but I have serious concerns about the claim in the title that, “More than a third of nurses have PTSD.”
When this is reiterated in the piece, this claim changed to say more specifically that, “up to 40 percent of nurses suffering symptoms of post-traumatic stress disorder (PTSD).” There is a significant difference between having a PTSD and having symptoms of PTSD as the physician authors of this piece can surely appreciate. This distinction should have been made so as to not have the inaccurate title that is currently in place.
This leads to the question of whether the claim is even accurate. When we look at the referencing of this claim, it is a link to a document from the Canadian Federation of Nursing Unions. In the document that is linked to, the claim is further referenced back to a document from the Manitoba Nurses Union (MNU).
Though the link to this MNU publication is dead, this document can be located through an internet search. In this document, it is stated that, “The exposure to mentally exhausting and challenging work is not openly discussed or recognized publicly even though research claims now identify that 30 to 40% of nurses are suffering from PTSD.”
At the end of this sentence they reference, “Laposa, J., and Alden, L. (2003). Posttraumatic stress disorder in the emergency room: exploration of a cognitive model. Behaviour Research and Therapy 41, 49-65.” The abstract for this study was located on PubMed (https://www.ncbi.nlm.nih.gov/pubmed/12488119). It is notable that it is a small survey of 51 emergency room personnel. In the abstract they state that, “Twelve percent of participants met formal diagnostic criteria for PTSD, and 20% met PTSD symptom criteria.” I do not have the access to the full text to see whether anything closer to the 40% number is mentioned in some other context.
While we certainly need to be concerned about physician and nurse wellbeing, I am disappointed to see a clickbait-style headline on a piece on this site that then goes on to make a claim from a labour union that does not seem to be backed up with research. I would respectfully suggest that the title be modified for accuracy and that the reference to the PTSD symptom claim be made to an appropriate source or that the claim be appropriately modified.
Primarily it is doctors and nurses who suffer burnout but some hospitals are so understaffed it’s also unit/ward clerks who suffer burnout.
I too have been there. Now at this point in my career have taken a position teaching psws. What a wonderful way to exit my career in a couple of years. For those of you, with burn out, please take time off for yourselves. Because nobody in this industry really cares how tired and worn out we are.