Stress, Grief and Emotional Health in the NHS Workforce

May 2018

To mark Mental Health Awareness Week and Dying Matters Week, Agnes Arnold-Forster (Research Fellow) and Alison Moulds (Engagement Fellow) discuss stress, grief and emotional health in the NHS workforce.

Credit: Adrian Wressell, Heart of England NHS FT
Credit: Adrian Wressell, Heart of England NHS FT

Mid-May marks Mental Health Awareness Week and Dying Matters Week. The former seeks to increase awareness and understanding of mental health, while the latter highlights the importance of talking about dying, death and bereavement. These two imperatives are interlinked, especially within healthcare – an open dialogue about the effect of losing patients and loved ones can help promote a more compassionate and emotionally healthy working environment.

Crucially, the theme of MHAW this year was stress, an emotion commonly associated with the health service. Indeed, discussions of burnout among healthcare practitioners have become almost ubiquitous in recent years. In a Guardian article published earlier this week, NHS staff were framed as needing to ‘do more’ to support those suffering from stress but also represented as particularly vulnerable to stress, anxiety and depression themselves due to the nature of their work. They face systemic issues such as under-resourcing and a fraught work-life balance, as well as emotionally charged encounters with patients who may be feeling vulnerable. There is a central tension at play here - practitioners are expected to support others but also need access to support themselves.

Modern surgery has seen improved patient outcomes, and deaths during or after operations are now much rarer. While you have a 3.6% chance of dying within two months of surgery, only between 1 and 30 in every 100,000 patients die on the table itself. A recent questionnaire survey in the British Medical Journal reported that only 53% of orthopaedic surgeons have ever witnessed an intraoperative death.

This situation is likely to continue as technological interventions are refined. Surgeons who do lose patients may, therefore, find it more difficult to deal with feelings of grief and loss. Agnes’ forthcoming research argues that patient death takes an under-appreciated emotional toll on surgeons, but also that it is deployed as a narrative device through which surgeons construct their professional identity. For example, surgeons’ early experiences of patient death could stay with them for the rest of their lives and be used as ways to delineate the boundaries of their professional ‘detachment’.

In his autobiography Do No Harm neurosurgeon Henry Marsh reflects, ‘I remember working all night trying, and failing, to save one man, fully awake and suffering horribly, who looked into my eyes as he bled to death from oesophageal varices’ (p. 146). Marsh repeatedly comments on what he calls his ‘defensive psychological armour’ that protected him from the emotional consequences of patient death. However, this armour had its chinks. Certain conditions of patient death made it impossible for him to disregard feelings of sorrow and distress.  

As a casualty officer I would have to certify death in some poor soul who had collapsed and died in the street. On these occasions I would find their corpse fully dressed on a trolley, and having to undo their clothing to place my stethoscope on their heart was a profoundly different experience from certifying death in the hospital inpatients in their anonymous white gowns. I felt that I was assaulting them, and I wanted to apologise to them as I unbuttoned their clothes, even though they were dead. It is remarkable how much difference clothing makes (pp. 146-147)

Commentators have suggested that certain experiences of patient death might affect a surgeons’ ability to operate subsequently. Following an inquiry into the deaths of two patients at Falkirk Royal Infirmary, the keyhole surgery pioneer Professor Sir Alfred Cuschieri said, ‘a death on the operating table of a patient is a harrowing experience for a surgeon. In my view, the surgeon is emotionally and mentally not in the frame of mind to continue to operate that day’. Sheriff Albert Sheenan recommended that surgeons should not operate for 24 hours after the intra-operative death of an elective surgical patient.

However, we also know that the ‘labour’ of death is increasingly being shifted out of the operating theatre, off the surgeons’ hands, and onto those of intensive care physicians, palliative care professionals, and nurses. Thus, patient death is an interesting subject for us as historians, not only because it is emotionally intense and laden with cultural baggage, but also because surgical experiences of patient death have changed substantially over the last thirty years as the focus of surgical work has narrowed and practice has become more specialised.

Practitioners perhaps need support services that can understand the unique challenges of working in the health service. We welcome initiatives such as the Practitioner Health Programme, the British Medical Association’s Counselling and Doctor Advisor services, and the Doctors’ Support Network, that focus on helping practitioners’ emotional and mental wellbeing. At an organisational level, we are pleased to see the use of Schwartz Rounds, reflective practice sessions for staff from all disciplines to discuss difficult emotional issues arising from patient care. We highlighted the value of these initiatives in our submission to the Royal College of Surgeons’ (RCS) Commission on the Future of Surgery. Yet research has also shown that surgeons are among the least likely of all medical practitioners to seek help for mental health problems, perhaps due to ‘group norms’ that traditionally inhibit discussion of emotional problems at work. In order for interventions to be effective, we also need to tackle the cultural stereotype of the detached and stoical surgeon.

At our ‘Operating with Feeling’ workshop at the RCS on Friday 1 June, we’ll be running sessions on ‘Stress, Burnout and Bullying’, ‘Anxiety, Doubt and Grief’, and ‘Compassion and Sympathy’. We feel that the role of these emotions in surgical and medical practice needs greater attention. Each session will feature presentations from a range of experts (practitioners, historians and policymakers) and breakout discussions, in which attendees will devise ideas for improving and enhancing surgical education, training, practice and patient care. We’re really pleased to welcome attendees from across the health service, as well as others, to take part in these important discussions. We want to ensure that the perspectives of the surgical team are represented. There’s still time to register to join us on the day and for those that can’t make it, we’ll be publishing a summary of the workshop on our website.