Burnout or Moral Injury – could coaching for all doctors be a worthy investment?

Jul 29, 2024

Today, I spent time organising all my posts and found this one (unpublished) from my early days of writing. Although I wrote it in 2021, I think it is just as relevant today. I’m hopeful that the change in government in the UK will bring about a change for all healthcare professionals working so hard in the NHS. It is a referenced opinion piece, written from the heart.

Burnout or Moral Injury – could coaching for all doctors be a worthy investment?

Dr Lucinda Homer

MBChB, FRCA, DAvMed

12/10/2021

Burnout in doctors is in the headlines and has been increasing year on year (1)(2). The impact of the COVID- 19 pandemic has exacerbated a growing problem and pushed many doctors to consider leaving the NHS and jobs they once loved.

The Royal College of Anaesthetists (RCoA) launched Fit for the Future (3) in February 2021, with one of its aims to address, what anaesthetic departments and managers can do to support mid-career anaesthetists and anaesthetists approaching retirement, so that they can continue to make a meaningful contribution at a time when the NHS is facing unprecedented staffing pressures.

In their most recent publication “Respected, valued, retained – working together to improve retention in anaesthesia” (4), The RCoA highlights a worrying shortage of Anaesthetists. The current shortfall “... equates to one million surgical procedures having to be delayed every year unless anaesthetic workforce numbers are increased to meet patient demand.”

The Key findings are not surprising, to me, and explain why so many doctors currently feel the way I felt in 2016 before I left my Consultant Anaesthetist post at the age of 47 after 14 years in post.

Some of the reasons, in the RCoA report, Anaesthetists gave for leaving:

· not feeling valued or well supported, including relationships with colleagues and managers

· bureaucracy and leadership issues

· improving mental wellbeing, reducing stress or burnout

· lack of autonomy and respect

Some of the factors which would influence Anaesthetists to stay longer:

· being able to work flexibly and less than full-time to have better work-life balance

· being able to adjust clinical practice or the environment to account for physical changes with age

· having supportive colleagues and managers that are respectful and appreciative

The Executive summary, “... paints a concerning picture of a workplace culture which does not always facilitate career progression and flexible working, leading valuable and experienced staff to leave often out of frustration with unsustainable workloads and lack of the adjustments required to keep them in work.”

The report makes 18 recommendations at an Individual, Organisational and System level, which demonstrates recognition, that the problem is not just down to the resilience of the individual.

Moral Injury

The term burnout implies a failure of the individual to cope, however there is another view which is gaining traction in various parts of the world. Dr Wendy Dean and Dr Simon Talbot, founders of Moral Injury of Healthcare (5), explain moral injury:

“Moral injury occurs when clinicians are repeatedly expected, in the course of providing care, to make choices that transgress their long standing, deeply held commitment to healing. It reframes the challenge of distress from “burnout”, which suggests a lack of resilience on the part of clinicians, to one that more accurately locates the source of distress in a conflict-ridden healthcare system.”

I certainly struggled with being asked to do increasingly more with less and less. The management structure was top-down and command and control in nature. Senior management decided what we needed to do to improve performance. We could voice an opinion, but it was not listened to and ideas for alternative solutions were not valued. A huge resource of clinician problem solving talent was ignored. The resulting lack of autonomy and dismissive management approach led to poor morale and a group of Senior Consultants who felt undervalued. This drip feeds throughout the organisation and affects recruitment and retention of staff at all levels.

I was not the only Consultant in my 40s to leave our department that year and more followed. I moved sideways into Aviation Medicine and now work for myself, as an Aviation Medical Examiner and Executive Coach.

Why Coaching?

I was familiar with mentoring as it was an integral part of our training provision for trainees. As a College Tutor and Educational Supervisor, I had been mentoring for years but I had never heard of coaching.

The NHS Midlands Leadership Academy (6) states:

“Coaching is one of the key approaches which aims to support leadership development. It is a method of developing an individual’s capabilities using questioning techniques which enable the individual to become more self-aware, resilient and confident. Coaching is often perceived as the single most effective development opportunity that a leader in the NHS can access:

· The relationship has a set duration

· It is structured with regular scheduled meetings

· Short term and focussed on specific development issues, issues goals and work

· The coach does not need to have experience of the coachee’s role”

When I was wrestling with the idea of a major career change, I read blogs, articles, books, listened to podcasts and spent a long time working out what I really wanted to do. It would have been a lot easier to make decisions and plans if I had had a coach. I decided to train as an Executive Coach to replace the teaching, training and people development role I missed following my departure from the NHS.

How is Coaching relevant in the NHS?

The world of business has known about Executive coaching for a long time. Doctors are not trained to be executive leaders at medical school. Executive level roles within the National Health Service (NHS) are widely performed by doctors, most of whom learn on the job. I believe that all doctors could really benefit from Strategic Mentoring or Coaching to maximise their potential as leaders. All doctors have a wealth of transferrable skills, which most of them do not realise they have, at their fingertips. This is a valuable resource which is often over-looked and underused.

When I trained to become an ILM level 7 qualified Executive Coach, I learnt a lot about organisational strategy, culture, context and conditions where a coaching culture could be effective.

I think that the “Performance Curve” (7), is particularly useful to illustrate cultural mindset and how this relates to Maslow’s hierarchy of needs (8). For an organisation to make improvements, the leader(s) needs to be aware of where it sits on the continuum. The strategic purpose of coaching is to act as an enabler for the leaders to set goals and move towards Interdependence. At this point they will find that they spend less time fighting fires and telling people what to do. They will have more time to develop their employees and a transform the culture within their organisation.

From my personal experience, there is a predominantly “Transactional” culture in the NHS. The use of a Transactional Leadership style pervades, as described by Kendra Cherry (2020) (9):

· People perform their best when the chain of command is definite and clear.

· Rewards and punishments motivate workers.

· Obeying the instructions and commands of the leader is the primary goal of the followers.

· Subordinates need to be carefully monitored to ensure that expectations are met

This management approach creates a dependent culture as described by “The Performance Curve” (6). The cultural characteristics described by Whitmore (2017) (9) include:

· staff who have a strong group identity and need to fit in.

· communication tends to be one way (top down).

· low engagement and trust

In contrast to this a “Transformational” leadership style, as described by Bass (10), is characterised by leaders who inspire:

· Individualised consideration (development of employee’s skills and enabling them to achieve their desired outcomes. These leaders offer coaching and treat employees as individuals).

· Intellectual stimulation (leaders promote a culture in which employees develop intelligence, rational thinking and problem-solving skills).

· Inspiration through effective communication of purpose and goals.

· Charismatic leaders, who try to gain respect and trust from employees. They encourage a sense of pride so that employees want to achieve desired outcomes.

If the context of an organisation does not value transformational leadership, teamworking and innovative ways to integrate care, then it will not value the power of an Executive Coaching programme to facilitate transformation of an NHS Trust.

My research into Executive coaching in the NHS was revealing and explained (in part) why I had never heard of coaching and why most of my colleagues also do not understand what I do. I discovered that it was available for NHS Senior leadership (12) roles above the level where most Consultants work. There are NHS leadership courses (13) available for a select few clinicians (numbers for courses are limited) but I was underwhelmed with what remains available for all doctors in training, SAS and Consultant posts. This is starting to change slowly.

Leadership skills are recognised by the GMC (14) as integral and important for all doctors. The most junior doctors find themselves in leadership roles early on in their careers and leadership skills need to be taught from medical school upwards to all doctors, and NOT just those interested in management roles.

Coaching cannot teach all the leadership skills required by doctors, but a blended approach with alternative learning strategies (15) provides the optimal results. Learning needs to translate into action in the workplace, for it to have a beneficial impact on productivity and well-being within an organisation.

There are barriers to adopting a coaching style of leadership, for example NHS Trusts typically have Chief Executives who do not stay in post for the long haul, they have financial and time pressures to perform and achieve government set targets. The culture of fear and blame is still very evident in the NHS and impacts on many areas in the organisation. There is also a pressure to demonstrate a Return of Investment (ROI), and a resistance to invest in alternative approaches. The NHS comes in for much negative press if all funds are not seen to be spent on patient care. However, the managerial infrastructure demands investment if the organisation is to improve performance. If a coaching style of leadership was adopted, then Senior Executives and clinicians could work in partnership to create highly performing teams and improve overall performance throughout the organisation. This would improve the quality and safety of the care provided, as well as empower staff to make valuable improvements in productivity.

The NHS People Plan (16) states that: ‘Employers should ensure that staff who are mid-career (aged around 40 years) and those approaching retirement (aged 55 years and over) have a career conversation with their line manager, HR and occupational health.’ I would argue that the conversation needs to start much sooner if we are to prevent and manage all the workforce problems we face currently.

During the COVID-19 pandemic the main context in the NHS has been to take care of a huge surge in numbers of patients with a specific disease. All other routine treatments were side-lined and now there is a large backlog of clinical work to clear as things start to return to “normal.” The workforce is exhausted and needs time to recover both physically and mentally.

There is forward movement in recognising that coaching is a valuable resource and there are already some excellent coaching initiatives implemented within the NHS. This is just the start and I believe coaching should be widely available for all doctors. The ripple effect of coaching is far reaching and has many positive outcomes for all stakeholders from the NHS as an organisation, to patients, doctors, their friends and families.

So, to answer my question in the headline, I believe that the current state of our healthcare system has caused and continues to cause Moral Injury to an enormous number of its workforce. This process started long before the COVID-19 pandemic, but it has been acutely exacerbated by it and we find ourselves at crisis point. The symptoms, that many staff are feeling, fit with those apportioned to burnout, but it is not the fault of the individual and they should not need to develop even more resilience to cope in a broken system. It is time for systemic change and while I am not naïve enough to think we will inhabit a land of unicorns and rainbows, I do believe that coaching has a place in the physical and mental recovery of staff, the ability to help doctors develop into Transformational leaders and an NHS worth keeping alive. It is time for the system to respect, value and retain its staff.

References:

1. https://www.rcoa.ac.uk/policy-communications/policy-public-affairs/views-frontline-anaesthesia-during-covid-19-pandemic, RCoA, 2020

2. https://www.gmc-uk.org/-/media/documents/national-training-survey-results-2021---summary-report_pdf-87050829.pdf, GMC, 2021

3. https://www.rcoa.ac.uk/policy-communications/policy-public-affairs/anaesthesia-fit-future, RCoA 2021

4. https://rcoa.ac.uk/sites/default/files/documents/2021-09/Respected_valued_retained2021_0.pdf, RCoA 2021

5. https://www.fixmoralinjury.org/, 2018

6. https://midlands.leadershipacademy.nhs.uk/, NHS

7. https://www.performanceconsultants.com/the-performance-curve, Performance Consulants, 2017

8. https://www.simplypsychology.org/maslow.html, McLeod, S 2020

9. https://www.verywellmind.com/what-is-transactional-leadership-2795317 Cherry, K, 2020

10. Whitmore, J. (2017). Coaching for Performance. 5^th Edition. UK, Nicholas Brealey, 2, 27-28

11. Bass BM. From transactional to transformational leadership: learning to share the vision. Organ Dyn. 1990;18(3):19–31.