Bull World Health Organ 2019;97:585–586 | doi: http://dx.doi.org/10.2471/BLT.19.020919 585
News
For Dr Advik Gupta (name changed
at his request) the crisis began with an
overwhelming sense of futility. “I would
get home to my wife and say I have
achieved nothing today, even though I
had been working flat out,” he says.
One of four consultant emergency
physicians working in the emergency
department of a district hospital in
Cape Town, South Africa, Gupta was
used to the life or death pressures of
emergency care.
“The hospital is in an area notorious for its gang violence,” he says.
“Around 4500 patients came through
the department every month.” On a
normal weekday roughly 30% of the
patients were the victims of violence,
but on the weekends the number and
mix of cases changed. “On Friday
nights there was a spike in penetrating
trauma cases – mostly stab wounds and
gunshot-related injuries.”
On such days as many as 80 acute
trauma cases went through the department, overwhelming the hospital’s
capacity to serve them.
Gupta is keen to emphasise that
it was not the stress of dealing with so
many acute trauma cases that made him
feel like giving up, it was the chaos he
experienced daily. As is often the case
in health systems that lack effective
primary care and referral systems, the
emergency department had become the
first port of call. Many of the less acute
cases would have been better served by
a primary health-care clinic or by social
services.
“Burn-out is not
just linked to the
health of the doctor, it
also affects the safety
of the patient.
Richard Heron.
”
Unable to cope, Gupta felt a strong
sense of failure and shame. Like many
people experiencing burn-out, he felt
a compulsion to prove himself. “I
tried harder,” he says. “Got in earlier,
worked late.” It made no difference,
and in the end, he decided to leave
the hospital.
According to the World Health
Organization’s (WHO) International
Classification of Diseases (ICD), people
experiencing burn-out typically feel
exhaustion, but are also likely to feel
detached or cynical about their job. They
often perform less well at work, putting
their patients at risk.
It is unclear how many people
working in the health sector globally suffer from burn-out, as most
research on this has been done in
high-income countries. However, a
recent survey by the International
Occupational Medicine Society Collaborative, representing occupational
medicine societies in 42 countries,
provides some estimates.
The survey elicited responses on
burn-out from health professionals
from 30 countries across the income
scale. Different comparability issues
preclude drawing firm conclusions
from the survey, but focusing solely on
doctors reporting burn-out, the survey
reported burn-out proportions ranging between 17.2% (Japan) and 32%
(Canada), with Austria and Ireland
reporting proportions comparable to
those in Canada.
Dr Richard Heron, co-chair of the
International Occupational Medicine
Society Collaborative, draws attention
to common drivers of burn-out, including excessive work-load and high
patient expectations. These factors are
complicated by an increased number
of patients presenting with chronic
diseases.
“There is an increased demand for
services across the spectrum of health
care, notably for the treatment of musculoskeletal, mental health conditions and
other noncommunicable diseases such
as cancer and heart disease,” Heron says.
As people age, he adds, they are also
more likely to be living with multiple,
chronic diseases, imposing a demand
for more complex treatments and integrated care.
At the same time, the promise of increased access to services in the context
of universal health coverage, inevitably
raises expectations.
For example, in 2009, China made
a formal commitment to achieving
universal health coverage for its 1.4
billion people and in the past 10 years
health authorities have come close to
achieving this goal with basic service
coverage reaching more than 95% of its
population.
Increased service provision has
been matched by a sharp increase in
outpatient and hospital admissions.
According to Professor Min Zhang,
from the Chinese Academy of Medical
Sciences, between 1995 and 2015, the
number of outpatient visits in China
increased by 100%. Admissions to public health institutions increased almost
300%. Meanwhile, the number of
licensed physicians across China has
increased by only 58%. China now has
around 1.9 doctors per 1000 people
compared to a high-income country
average of 3.4.
“The disparity between capacity
and demand has led to an overburdened
workforce, increased waiting times and
Health workforce burn-out
Increased demand for health services is putting unprecedented strain on health systems and the workers within them.
Many are experiencing burn-out, depriving health systems of their most vital resource: people. Lynn Eaton reports.
Professor Min Zhang discusses occupational health
with infectious disease specialists at a hospital in
Guangxi Zhuang Autonomous Region in China.
Courtesy of Min Zhang
586 Bull World Health Organ 2019;97:585–586| doi: http://dx.doi.org/10.2471/BLT.19.020919
News
a lower quality of service than patients
expect,” says Zhang.
Heron sees this dynamic expressed in many countries. “Quality
suffers where staff are unable to cope,”
he says. “The compassionate, caring
environment is harder to maintain
and mistakes are more likely. Burnout is not just linked to the health of
the doctor, it also affects the safety of
the patient.”
In China and elsewhere, dissatisfied patients have attacked health
workers. For Zhang, patient violence
and health worker burnout are two
sides of the same coin. “Burn-out contributes to workplace violence, then
workplace violence contributes to
burnout,” she says.
Of course, the harms caused by
burn-out are not limited to suboptimal
care and patient dissatisfaction. Burnout is also associated with increased
absenteeism and turnover, which disrupts organizational function, reduces
team efficiency and causes a loss of
institutional knowledge.
What can be done to address this
issue? Health professionals responding to the International Occupational
Medicine Society Collaborative survey
proposed interventions, such as improving work conditions and reducing
or changing tasks.
They also emphasized the need
for monitoring, early diagnosis, and
psychosocial risk factor prevention
programmes.
“There has been
too much focus on
the individual in
addressing the burnout problem.
Advik Gupta.
”
Some low and middle-income
countries are already implementing
burn-out prevention or mitigation
programmes. In Togo, for example,
the Ministry of Health and Public
Hygiene has been working with
WHO and the International Labour
Organization (ILO) on ways to avoid
burn-out alongside other occupational hazards, such as infection risk
and working in extreme heat. The
psychosocial factors that might lead
to burn-out are being assessed at 10
pilot sites.
“We have an occupational psychologist and an occupational nurse
to help detect burn-out and build a
strategy to prevent it,” says Dr Silvère
Kevi, coordinator of occupational
safety at the Togo health ministry. The
project is just beginning and so it is
too early to assess the impact.
In Sri Lanka, the Ministry of Health,
Nutrition and Indigenous Medicine is
starting with an occupational health,
safety and wellbeing programme for
health-care workers this year.
According to Dr Inoka Suraweera,
at the health ministry, it may be too
soon to conclude that understaffing
is the core burn-out issue.
“Poor staffing levels may be responsible,” she says, but more evidence
needs to be generated in this area,
especially to support the planning of
interventions. In my opinion, we need
to study the effect of culture on this
issue too, especially on coping.”
China has been collaborating
with ILO and the China country office of WHO since 2013 on the use of
a quality improvement tool for health
facilities known as HealthWISE. The
tool encourages managers and staff to
work together to improve their workplaces and practices.
By dubbing burnout an ‘occupational phenomenon’ and defining it
as a syndrome “resulting from chronic
workplace stress that has not been successfully managed”, the ICD classification places as much emphasis on the
workplace as the worker, suggesting
that any meaningful response is going
to require action on both sides of the
equation.
Advik Gupta welcomes this approach. “Until now there has been
too much focus on the individual in
addressing the burn-out problem,” he
says. “We need to see it from a health
system point of view.”
Dr Ivan Ivanov, Team Lead, Global
Occupational and Workplace Health at
WHO headquarters, concurs, seeing
occupational burnout as a symptom
of poor working conditions in the
health sector.
“Ensuring decent working conditions in the health sector is a priority”
he says, “and WHO and the ILO are
working together to stimulate countries to develop national programmes
for protecting the occupational health
of health workers.” ■ An emergency room of a tertiary hospital in central China’s Henan province.
Courtesy of Min Zhang
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.
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