Supporting the wellbeing of surgeons and surgical teams during COVID-19 and beyond
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Summary of key points
Studies have shown that although surgeons have elevated risk for burnout and depression, they are unlikely to seek help. This can have a detrimental effect on performance and patient safety, and is currently aggravated through the added burden of the COVID-19 circumstances.
The Royal College of Surgeons of England (RCS England) has developed this brief guide for surgeons and healthcare managers with advice on how to recognise when mental health is being compromised and what to do about it. This includes:
1. How to recognise when something is wrong, including:
- recognising the symptoms of burnout such as depletion of energy, apathy or negative feelings towards patients, colleagues and their work, and reduced professional efficacy
- understanding the three phases of psychological response to crisis (emergency, regression and recovery, and how to support your team through them)
2. What individual surgeons can do for self-care, including:
- using confidential self-screening questionnaires to assess their mental fitness
- taking advantage of available support such as the RCS Eng Confidential Advice and Support Service, British Medical Association counselling support, NHS Employers wellbeing apps and other resources (full list provided in the guide)
- nurturing supportive relationships with colleagues and tapping into peer support networks
3. What hospitals and healthcare managers can do to support staff, including:
- establishing effective and transparent communication
- supporting basic needs of staff (childcare, access to food, and transportation)
- promoting wellbeing, including appointing a chief wellness officer, establishing a crisis response team to provide psychological first aid in traumatic events, carrying out daily virtual peer support groups, online wellbeing toolkits and offering regular mental health evaluations
- adjusting work schedules and distributing workload appropriately to mitigate against the added pressures of the pandemic
In recent years, studies have shown that although surgeons have elevated risk for burnout and depression, they are least likely to seek help. Mild psychological illness and burnout are linked to poor clinical and academic performance, increased errors, poor empathy, dishonesty and substance misuse, ultimately leading to detrimental effects on patient safety.
The effect of the COVID-19 pandemic offers an added burden on the mental wellbeing of the surgical workforce and may exacerbate such issues. Research carried out in China in March 2020 highlights the mental health risk that UK healthcare workers potentially face. The study, published in the JAMA Network Open Journal, involved 1257 healthcare workers during the coronavirus pandemic. It found that 50.4% had symptoms of depression, 34.0% reported insomnia, 44.6% reported symptoms of anxiety and 71.5% reported distress. It concluded that working on the frontline during the pandemic was an independent risk factor for worse mental health outcomes in all dimensions.
NHS staff caring for patients with contagious and life-threatening illnesses are likely to have anxiety and fear of being infected as well as fear of infecting family members. Added workload, uncertainty over the surges of the pandemic, social isolation and shortages of personal protective equipment or testing equipment may provoke feelings of anger, frustration and helplessness over the events they are facing. Usual ways of coping are likely to be challenged and if staff are unsupported, symptoms of distress and burnout will decrease their ability to function effectively.
This guide provides advice for members of the surgical team and those who manage them on how to address any adverse effects of decreased mental health, support well-being, promote surgeons’ inherent resilience, and increase work-life integration and satisfaction.
Burnout: an ‘occupational phenomenon’ augmented by COVID-19
A 2018 survey by the American College of Surgeons found that 52% of surgeons report burnout. Burnout is most commonly defined as a state of depersonalisation (loss of empathy), emotional exhaustion (emotional fatigue) and a sense of reduced personal accomplishment (competence and achievement).
According to the World Health Organization, burnout results from chronic workplace stress and is characterised by depletion of energy and exhaustion, apathy or negative feelings related to one’s job, and reduced professional efficacy. Burnout affects how engaged surgeons are with their patients, colleagues and their work, and is associated with poorer patient satisfaction and clinical outcomes.
Factors contributing to burnout mirror the conditions of the COVID-19 pandemic. They include excessive workloads, patient pressures, lack of control, insecurity, reorganisation, poor support, anxiety over personal competence, front line practice, perceived threats of complaints and dysfunctional workplaces. The effects of burnout are both personal and systemic. On a personal level, burnout is correlated with depression, anxiety and suicidal ideation. It affects personal and professional relationships. Those experiencing burnout are much more likely to express a desire to leave the profession. Systemically, burnout can be associated with increased attrition and dropout rates.
Conversely, a supportive work environment that promotes a positive culture and allows for autonomy and decisional authority can mitigate many of the above factors. Physical activity and having a positive family life outside of work is also directly associated with lower levels of burnout.
Some professional decisions during the pandemic may further result in moral distress. Symptoms of moral distress include self-criticism as well as excessive feelings of shame, guilt and regret. This moral distress and anticipatory grief can be difficult to cope with, and additional support may be helpful to address their harmful effects.
1. How to recognise that something is wrong
There are several validated tools to measure burnout (eg the Maslach Burnout Inventory) but general signs include sadness, depression, irritability, frustration, poor hygiene, social isolation, feelings of hopelessness and low job satisfaction. Anxiety, (including ruminations about witnessed events and difficulties sleeping) is also a common sign of burnout.
In the context of prolonged crises such as the COVID-19 pandemic, such symptoms often appear at a much later stage, following an initial period of intense focus and feeling energised to manage the challenge ahead. The adrenaline-fueled pace of the initial crisis response begins sputtering, and problems become more complex and exhausting. This can affect individual surgeons but also the way in which the surgical team collaborates.
Psychologists have identified that crises such as the COVID-19 pandemic follow a specific pattern of three phases (emergency, regression and recovery):
- The initial phase of EMERGENCY is characterised by clear shared goals and a sense of urgency that affords energy and focus. Individual performance and team productivity increase.
- This is followed by REGRESSION, when there is the realisation that the future is uncertain, fatigue sets in, people’s sense of purpose diminishes, and they experience irritability, withdrawal and reduced productivity.
- The final phase is RECOVERY, when one begins to reorientate psychologically, revises expectations and roles, gains perspective on the crisis, and moves on to rebuild the future.
Recognising this cycle and accepting that the regression phase is unavoidable can help people move through the toughest part of the crisis in a constructive way, mitigate the drop in performance and get to the recovery phase. Team leaders can usually help their teams come out of the regression phase through the following actions:
- resetting the team structure and assigning new responsibilities to team members, allowing them to cut through rigid role definitions, hierarchies and red tape;
- calibrating the team members’ emotions by encouraging them to be kind to one another and fostering an environment where it is safe and legitimate for all to be honest about their state of mind so that the team can begin to move forwards;
- reorientating the team beyond crisis management. Instead of attending only to the immediate need, it is helpful to start facing the future, anticipating what is next and where the team can provide the most value.
2. What individual team members can do for self-care
During the COVID-19 pandemic, it is important to take the time to preserve one’s own wellbeing amidst the increased demands of caring for patients, providing support to hospital systems and staff, managing extra workload and navigating the impact COVID-19 on the community. Some suggestions for managing stress during this time are:
- Understand that what you are feeling is a normal response to a complex and uncertain situation. Most surgeons and doctors working during this crisis will be experiencing increased frequency of stress responses throughout the working day.
- Engage in consistent self-reflection to identify the emotional and mental signs of increased stress. Some emotional signs of stress include the persistence of fear, irritability, anger, deep sadness and feeling overwhelmed. Mental signs include loss of concentration, local memory loss, inability to make decisions, disorientation and confusion. You can speak to a friend or a peer, or you can use a number of free online self-assessment tools such as the British Medical Association’s confidential self-help questionnaires for self-screening or the Mayo Clinic’s anonymous wellbeing index, which assesses and tracks your overall wellbeing relative to the general working population.
- Prioritise your basic needs. Make sure you get adequate sleep, stay hydrated and eat healthily. Limit the use of alcohol and other substances. Exercise is a key component for wellbeing so make sure you engage in some physical activity every day.
- Take brief mental breaks throughout the day, including from your phone and computer. Make the effort to unwind, rest your mind and reset by finding a quiet space during work breaks or at home when off duty and focusing on something other than work, even for a short time.
- Stay connected to family and friends outside work. Social support systems are essential in a crisis to reduce feelings of isolation and help manage and replenish emotional resources.
- Create and nurture supportive connections with colleagues. Check in with colleagues and let someone know if you are struggling. Look out for signs that your own colleagues might need support and reach out where necessary. Peer support can be invaluable at times of strain. Consider establishing a ‘buddy’ system, and use quick check-ins (face-to-face, telephone, text or email) to provide encouragement and a sense of solidarity.
- Where needed, seek professional support to cope with moral distress and grief. This can include speaking to a colleague or your line manager, calling the RCS Eng confidential helpline for peer support, turning to your local trust human resources department or the local Freedom to Speak Up Guardian. (See also section 6 of this document for a detailed list of resources for accessing professional support.)
3. Recommendations for healthcare managers
Given the unprecedented pressures of the pandemic on NHS workers, it is more important than ever that hospitals create and maintain a critical infrastructure to support members of the surgical team. We recommend that hospitals and managers focus on the following four areas to support the wellbeing of staff:
A. Effective and transparent communication
Effective crisis management should provide a clear vision and a realistic plan. It should take decisive action and facilitate open, honest and frequent communication. In an unknown territory such as the COVID-19 pandemic, healthcare leaders will not have all the answers but it is important that they are present, and provide a voice of confidence and empathy that is timely, relevant and authentic.
In a crisis, information can reduce anxiety. Leaders should therefore share what they know and what they do not know, commit to finding answers and share them with their teams. Different forms of communication might be needed to stay connected with staff, such as emails, virtual meetings, frontline rounding and listening sessions. Effort should be made to express appreciation to staff for their work under difficult circumstances.
B. Supporting basic needs
As the demands on healthcare workers increase during the pandemic, employers should provide sufficient support so that they are able to meet basic needs. This includes personal and family safety, childcare (especially in families with two healthcare workers), access to food, transportation (realising the added cost when they have to take a taxi rather than the bus or underground).
Support measures could include low cost or free meal options, ‘pods’, with colleagues (to share childcare, eldercare or pet care), flexible schedules to provide relief and financial support for transportation. Hospitals can also provide lodging support for staff living apart from their families as well as safe and supportive spaces for rest and down-time, including quiet areas.
Finally, employers should ensure that healthcare workers have appropriate personal protective equipment in line with guidance by Public Health England
and the World Health Organisation as well as advice for healthcare workers to keep their family and friends safe when returning home from work.
C. Promoting wellbeing
Hospitals should develop a wellbeing strategy with access to high quality support services. This can include:
- appointment of a chief wellness officer to lead and monitor a professional well-being program;
- a crisis response team trained in relevant communication skills to provide psychological first aid and emotional support to staff who experienced a traumatic clinical event, tapping into existing employee assistance, chaplaincy or other wellness programs, with triage when needed to higher levels of support (including counselling);
- daily virtual meetings of peer support groups in which surgeons and members of the surgical team can discuss ongoing challenges and support one another. (Peer support is essential, as surgeons often feel more comfortable opening up with a surgical colleague rather than with a mental health professional who might not be able to relate to their exact circumstances as intimately.)
- online wellbeing toolkits where all relevant resources are centralised and easy for clinicians to access, including clear signposting to external resources that can provide psychological support (see for example section 6 of this document).
- regular and supportive assessment of stress and confidential mental health evaluation of staff to identify risks, specific drivers and emerging issues, and respond flexibly to their needs.
D. Adjust work schedules and workload distribution
In order to mitigate against the added pressures of the pandemic, healthcare managers should seek to:
- establish a plan to reduce non-essential tasks or delegate these to administrators and clinicians with extra time due to decreased regular services;
- rotate staff between high and low stress activities;
- make working-from-home arrangements where this is practicable;
- consider pairing up less experienced staff with more experienced colleagues, who can provide support, monitor stress and reinforce safety practices;
- implement flexible schedules for workers who are directly impacted by the outbreak or have a family member who is;
- ensure that paid time off and sick days remain unaffected for all staff with COVID-19 related illnesses.
RSC Eng Confidential Support and Advice Service
24/7 helpline providing advice to surgeons by a counsellor or peer support by a surgeon
0207 869 6221
BMA Counselling and peer support for doctors
Confidential 24/7 counselling and peer support services open to all doctors and medical students (regardless of British Medical Association membership), plus their partners and dependents
0330 123 1245
Independent and confidential psychotherapeutic consultation service, supported by the British Medical Association and the Royal Medical Benevolent Fund
BMA self-help Questionnaires
Confidential questionnaires for self-screening
Mayo clinic well-being index
Free and anonymous validated online tool allowing one to calibrate your wellbeing relative to the general working population
NHS Practitioner Health
Confidential mental health service for NHS practitioners
Sick Doctors Trust
Confidential support for doctors who are concerned about their use of drugs or alcohol
Free wellbeing apps for all NHS staff
Free and confidential psychological support service for people working in frontline services in the UK during COVID-19
Support for leaders during COVID-19
Coaching, mentoring and support networks for healthcare leaders
References and further reading
A full list of references and further reading can be found in the PDF download.