More than a third of nurses have PTSD symptoms; a third of doctors are burned out. What are we doing about it?
“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.”