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A study of the relationship between resilience, burnout and coping strategies in doctors
  1. R Scott McCain1,
  2. Nicola McKinley1,
  3. Martin Dempster2,
  4. W Jeffrey Campbell1,
  5. Stephen J Kirk1
  1. 1 Department of General Surgery, Ulster Hospital, Belfast, UK
  2. 2 School of Psychology, Queen’s University Belfast, Belfast, UK
  1. Correspondence to R Scott McCain, Department of General Surgery, Ulster Hospital, Upper Newtownards Road, Belfast BT16 1RH, UK; smccain01{at}qub.ac.uk

Abstract

Purpose of the study The aim of this study was to measure resilience, coping and professional quality of life in doctors.

Study design A cross-sectional study using an online questionnaire in a single National Health Service trust, including both primary and secondary care doctors.

Results 283 doctors were included. Mean resilience was 68.9, higher than population norms. 100 (37%) doctors had high burnout, 194 (72%) doctors had high secondary traumatic stress and 64 (24%) had low compassion satisfaction. Burnout was positively associated with low resilience, low compassion satisfaction, high secondary traumatic stress and more frequent use of maladaptive coping mechanisms, including self-blame, behavioural disengagement and substance use. Non-clinical issues in the workplace were the main factor perceived to cause low resilience in doctors.

Conclusions Despite high levels of resilience, doctors had high levels of burnout and secondary traumatic stress. Doctors suffering from burnout were more likely to use maladaptive coping mechanisms. As doctors already have high resilience, improving personal resilience further may not offer much benefit to professional quality of life. A national study of professional Quality of Life, Coping And REsilience, which we are proposing to undertake, will for the first time assess the UK and Ireland medical workforce in this regard and guide future targeted interventions to improve professional quality of life.

  • Human Resource Management
  • Mental Health
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Introduction

A career as a doctor can be incredibly rewarding. It can also be exceptionally demanding, with doctors reported to be at an increased risk of burnout, depression, anxiety and suicide in comparison with the wider population.1 2 It has been suggested that a doctor’s risk of burnout and other psychological morbidity is related to their resilience.3 Resilience can be defined as the ability to adapt well in the face of adversity or significant stress, even returning stronger afterwards. Psychologists have identified some of the personality factors that make an individual resilient, including positive attitudes, optimism, the ability to regulate emotions and the ability to see failure as a form of beneficial feedback.4 Environmental factors such as social support are also important in determining resilience.5

Although doctors’ physical health has been extensively studied and some effort has been made, particularly in the USA, to examine physician burnout, much less information is available on resilience. In a survey of Australian general practitioner (GP) registrars working within primary care, Cooke et al ascertained that the majority of doctors surveyed fell in the low–moderate resilience range (82%). Only 8% had high resilience scores and 10% had low resilience scores. They also demonstrated an association between high resilience and low burnout.3 Very limited information is available on coping strategies employed by doctors encountering adversity. Mache compared coping strategies between Australian doctors and German doctors, describing the range of coping strategies employed but including no analysis of burnout or resilience.6

In addition to the personal psychological morbidity associated with burnout, evidence suggests that poorly coping and burnt out doctors are more prone to medical errors.7 Understanding the relationship between physician burnout, resilience and coping strategies is therefore vital not only for the welfare of doctors but also for the welfare of their patients. The aim of this study was to evaluate resilience, professional quality of life (including burnout, secondary traumatic stress and compassion satisfaction) and coping strategies among doctors in a single National Health Service (NHS) trust. We assessed the impact of demographic variables such as grade, sex and specialty. A single qualitative question was asked, with the aim of ascertaining specific career time points at which resilience is low.

Participants and methods

All medical staff within a single NHS Trust were deemed eligible to participate in this cross-sectional study. The study took place during a 4-week period in August 2016. All doctors were invited to participate by email to internal trust email addresses. A repeat invitation was made on two further occasions. Invitations were sent to 230 hospital consultants, 224 junior medical staff and 110 GPs working on the trust out-of-hours service. Participation was voluntary and responses were anonymous. Approval was given from the Trust NHS Research Governance Committee (SET16:37). No ethical committee approval was required due to the study being carried out in doctors, who were participants by virtue of their professional role.

The survey consisted of an 80-item questionnaire to include three validated measures of professional quality of life, coping and resilience. Professional quality of life was measured using the Professional Quality of Life Scale (ProQOL) V, which gives a measure of burnout, secondary traumatic stress and compassion satisfaction. Burnout is associated with feelings of exhaustion, frustration, anger and feelings of hopelessness in doing your job effectively. Secondary traumatic stress is a negative feeling driven by fear and work-related trauma. Compassion satisfaction is the pleasure an individual derives from being able to help others and do their work well. Medical staff were invited to consider each statement and rank themselves appropriately on a Likert scale of 1–5 (1, never; 2, rarely; 3, sometimes; 4, often; 5, very often). Higher scores suggest higher levels of the component in question. Population norms for each component of the ProQOL are a mean of 50 and SD of 10.8 Additionally, each component of the ProQOL is divided into low (≤43), moderate (44–56) or high (≥57) to facilitate interpretation of scale scores in combination and allow identification of individuals who are most ‘at risk’.8

Coping was measured using a modified variant of the Brief COPE, an abbreviated version of theCOPE Inventory scale.9 It asks the participant to score themselves for specific coping methods on a Likert scale from 1 to 4. The score for each coping strategy is reported on a scale of 1–4. Higher scores represent more frequent use of the coping method in question.

Resilience was measured using the Connor Davidson Resilience scale.10 The scale has a total possible score of 100 with population norms of a mean of 50 and SD of 10. Higher scores reflect greater resilience.

The survey was completed with a qualitative question aimed to explore the causes of low resilience: ‘We would be grateful if you could inform us of a career time point when you have felt your resilience level may have been low’. The responses were analysed through two coding rounds. Initially data were coded descriptively to summarise themes within responses using a single word or short phrase. These themes were further subject to pattern coding by categorising descriptive responses.

Doctor numbers completing each part of the study can be seen in figure 1.

Figure 1

Flow chart of study inclusion and completion. CD-RISC, Connor Davidson Resilience scale; ProQOL, Professional Quality of Life Scale.

Data were analysed using SPSS V.22.0. The difference between specialty and grade was analysed using a one-way analysis of variance. The difference between specialty groups was analysed using the independent samples t-test. Potentially predictive factors for increasing burnout were analysed using a multiple linear regression model. Within the regression analysis, sex is a dichotomous variable, while the remaining variables are continuous. Individual linear regression coefficients are reported as crude coefficients in a univariable analysis, while adjusted coefficients are reported in a multivariable analysis. We assumed a linear relationship between continuous factors and burnout and confirmed this by examining partial regression plots for all continuous factors with burnout. We also examined collinearity diagnostics to ensure that there was no high collinearity between the factors.

Results

Surveys were completed by 283 doctors (150 males, 133 females) across a wide range of specialties and grades (table 1). The response rate was 52.2% for hospital doctors and 41.8% for GPs. GP respondents included those working in the trust out-of-hours service, and two GPs with Specialist Interests employed on a sessional basis by the trust.

Table 1

Number of doctors of each grade and specialty

Resilience was measured in 247 doctors. Mean resilience was 68.9 (SD 12.6).

Professional quality of life was measured in 269 doctors. Mean burnout was 55.2 (SD 9.6), mean secondary traumatic stress was 63.3 (SD 8.9) and mean compassion satisfaction was 49.3 (SD 8.9). When categorised into high, moderate or low groups, 100 (37.2%) doctors had high levels of burnout, 194 (72.1%) doctors had high secondary traumatic stress and 64 (23.8%) doctors had low levels of compassion satisfaction. For an individual to be performing well, they should ideally have low/moderate burnout, low/moderate secondary traumatic stress and high compassion satisfaction.8 Only 19 (7.1%) doctors fell into this category. On the opposite end of the scale, the most negative combination is high burnout and secondary traumatic stress and low compassion satisfaction. Fifty-one (19.0%) doctors fell into this combination category.

No significant difference in burnout, secondary traumatic stress, compassion satisfaction or resilience was evident when sex of doctor or different grades of doctor were compared. Due to the small numbers of doctors in some individual specialties, specialty was categorised into surgical and non-surgical specialties and hospital doctors and GPs. Surgical specialties were significantly different to non-surgical specialties, with higher compassion satisfaction, lower secondary traumatic stress and lower burnout. GPs had significantly higher burnout than hospital doctors (table 2).

Table 2

Burnout, secondary traumatic stress, compassion satisfaction and resilience in different grades and specialty groups

Coping mechanisms employed can be seen in table 3. Individual coping strategy means are lower than in other studies.6 The two strategies with the highest mean scores are self-distraction and self-blame, both considered to be dysfunctional coping strategies. If the dysfunctional strategies are further examined, those with more potential to cause harm to patients, family or colleagues, such as substance use, behavioural disengagement and venting are employed relatively infrequently.

Table 3

Coping strategies employed by doctors

Potentially predictive factors for the development of burnout were analysed using a linear regression model (table 4). In our model, substance use, behavioural disengagement, self-blame, high secondary traumatic stress, low resilience and low compassion satisfaction were positively associated with burnout.

Table 4

Linear regression model for increasing burnout

Qualitative results

When individuals were asked to describe a career point at which their resilience was perceived to have been low, there was a wide range of responses. The responses were categorised into themes (table 5).

Table 5

Emerging themes and quoted responses to qualitative component

In total, 168 doctors completed the qualitative part of this study. Eleven doctors stated their resilience had never been low, with some reinforcing this by the use of exclamation marks or smiling emojis (☺). Twelve doctors stated that they were currently at their lowest point, with some describing their job as the most stressful it has even been. Sixteen doctors raised issues outside of work, including illness or death of a family member or equivalent, and having young or newborn children.

The majority of issues raised were professional in nature, with 138 doctors referring to adverse events within work which lowered their resilience. For 59 doctors, these adverse events were clinical in nature, including excess workload, poor outcomes and mistakes. Some reference was made to the constant access to ‘work’, with trust tablet computers and a need to bring clinical administrative work home.

Non-clinical issues in the workplace dominated the feedback, with 78 doctors highlighting problems with career transitions (n=39), complaints and litigation (n=17), professional relationships (n=9) and senior-level support (n=13). Particular emphasis was placed on the step up from training grades to a consultant post, with many doctors feeling inadequately prepared for the transition. Some doctors stated their clinical practice and career planning were so badly affected by a complaint or litigation that they were actively pursuing early retirement. Professional relationships were problematic for some, mainly relationships between doctors, with doctors of varying grades stating that they had experienced undermining behaviour, lack of respect and bullying. Additionally, several doctors felt inadequately supported by either senior clinicians or senior management, particularly in the context of complaints, litigation or General Medical Council (GMC) referral.

One response seemed to summarise the difficulties facing doctors:

Resilience is impacted by trying to manage unmanageable demand. By the impossibility of balancing the needs/wants of patients with the resources of the organisation and its staff. By organisational and departmental decision making which is anti-science and anti-evidence. These and other factors combine to leave a sense of hopelessness and a desire to just ’get through it' rather than work hard for improvement and progress. Sometimes the most exhausting thing is to keep battling against this learned helplessness for the sake of patients and other staff.

Discussion

As in previously published studies worldwide, this study demonstrates high burnout in almost one in every two doctors. Associated with this was an increased likelihood of maladaptive coping strategies such as substance use.

While resilience in doctors is high, many doctors are suffering from secondary traumatic stress and burnout, and worryingly many have low levels of compassion satisfaction. A low level of compassion satisfaction can be the consequence of persistent burnout. If an individual has low compassion satisfaction in combination with high burnout and high secondary traumatic stress, it is unlikely to be beneficial for them to remain in or return to an unmodified work situation.8 In our cohort, 18% of doctors surveyed had reached this distressing point. When doctors were invited to consider career time points when their resilience was low, they identified workplace and systemic factors as being significant contributors to low resilience.

The implications of burnout on clinical care and patient safety have not been assessed in this study, but burnout has been strongly associated with clinician-perceived medical error in other studies. Causation, however, has not been shown. There have been no true studies of patient safety in this context, with outcomes reported including surrogate measures of patient safety such as error reporting and perceived medical error.7 11

Our study is subject to some limitations. This is a study of doctors in a single NHS trust and is therefore subject to selection bias. Our findings may not be reflective of other UK doctors. Our study has nonetheless shown similar levels of physician burnout to other published studies, suggesting it is likely to be a reasonable representation of the UK medical workforce. There was a response rate of 52.2% for hospital doctors and 41.8% for GPs, higher than in other similar questionnaire studies.1 7 Furthermore, a cross-sectional study such as this can only show association rather than causation. The limitations of this study will be addressed in a subsequent national study—Quality of Life, Coping And REsilience which we are proposing to undertake.

The major strength of this study is that resilience, burnout and coping have not previously been assessed in combination in UK physicians. In the context of doctors’ resilience being high, the current interest in personal resilience by the GMC and others, while well meaning, may offer little in terms of reducing burnout and associated medical errors. It may be more appropriate to concentrate efforts on improving the working environment, reducing associated stress and attempting to increase social resilience within the workplace.

Conclusion

In this study, physicians demonstrate high resilience. There are high levels of burnout and high levels of secondary traumatic stress. Workplace and systemic factors seem to play a role in low resilience. A national study of professional quality of life, coping and resilience will for the first time assess the UK and Ireland medical workforce in this regard and guide future targeted interventions to improve professional quality of life.

Main messages

  • Despite doctors’ resilience being higher than that of the wider population, doctors have high levels of burnout and secondary traumatic stress.

  • Doctors identified workplace and systemic problems as significant contributors to low resilience.

Current research questions

  • Are the findings in this study generalisable to other doctors in the UK?

  • This question will be answered by our proposed study (Quality of Life, Coping And REsilience) which aims to assess the wider UK medical workforce in this regard.

References

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Footnotes

  • Contributors SM and NM contributed equally to this study and can be considered joint first authors. SM designed the study, designed data collection tools, monitored data collection, cleaned and analysed the data and drafted and revised the paper. NM designed the study, designed data collection tools, monitored data collection and drafted and revised the paper. MD designed the study, analysed the data and revised the draft paper. WJC designed the study, analysed the data and revised the paper. SJK designed the study, monitored data collection, analysed the data and revised the paper.

  • Disclaimer The lead author SJK acts as the guarantor and affirms that the manuscript is an honest, accurate, and transparent account of the study being reported. No important aspects of the study have been omitted and there have been no discrepancies from the study as planned.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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