Job dissatisfaction,‘burnout’ and alienation of labour: undercurrents in England’s NHS

Background

The scale of staff shortages

The NHS is heavily reliant on professional staff with high-level clinical skills that take many years to acquire. It employs around 140,000 doctors (around 11% of the total workforce) and around 300,000 nurses and midwives (around 25%), as well as allied health professions, administrative and support staff, and technicians. ¹

The National Audit Office ¹ noted 50,000 vacancies across all types of clinical staff in 2014. It estimated a shortfall of 5.9% between the number of staff that NHS organisations said they needed (and had budgeted for) and the number of staff actually in post. More recent data suggest the position has worsened in nursing and midwifery, ² hospital medicine ¹ (including paediatrics), ³ mental health services, ¹ paramedics ¹ and general practice. ⁴ A recent report described staffing as the ‘make or break issue for England’s NHS. ⁵

While there are staff shortages across the whole of the NHS, the workforce needs to expand in particular services. For example, the aspiration to provide care closer to home, and to offer new models of care as outlined in the NHS Long-Term Plan, ⁶ depends on an expanding primary care workforce, not a decline in district/community nurses and general practitioners. Similarly, lower nursing levels on hospital wards are associated with higher hazards for patients, and more support workers or healthcare assistants do not offset this. ⁷

The NHS tends to underestimate the need for staff and overestimate the availability of practitioners. ⁸ The House of Lords Select Committee on the Long-term Sustainability of the NHS ⁹ confessed to being:

 … concerned by the absence of any comprehensive national long-term strategy to secure the appropriately skilled, well-trained and committed workforce that the health and care system will need over the next 10–15 years. In our view this represents the biggest internal threat to the sustainability of the NHS.

This is why the NHS is developing a workforce strategy within its Long-Term Plan, ⁶ promoting new roles such as Nursing Associates, ¹⁰ as well as expanding medical student places in an attempt to offset the shortfall in general practitioners. ¹¹ The report ‘Closing the Gap’, published jointly by the Health Foundation, The King’s Fund and the Nuffield Trust ⁵ details the training, skills and resources needed to stabilise and replenish the NHS workforce but is surprisingly reticent about how the negative experiences of NHS staff contribute to the workforce crisis. These plans and proposals are welcome but may not address some of the causes of job shortages, particularly widespread job dissatisfaction, ‘burnout’ and estrangement from healthcare provision. Some researchers argue that burnout (in particular) represents a public health crisis with negative impacts on individual practitioners, patients and healthcare systems. ¹² Burnout is seen by some commentators in the UK as threatening the very survival of the health service; Jordache, senior medical educator at the UK’s Medical Protection Society, asserts that ‘if burnout is not tackled, the NHS will fail’, ¹³ while Wilkinson portrays the harm done to the NHS by staff who are ‘stressed, exhausted and burnt out’. ¹⁴

While widely discussed, these concepts – job dissatisfaction, ‘burnout’ and estrangement – are poorly defined. The research literature focused on them is relatively thin, with a few recent systematic reviews, some studies using structural equation modelling and allied path analysis techniques, and a handful of intervention trials. This paper, based on a synthesis of this literature, is in four parts. Part 1 attempts to tease out the meanings and consequences of job dissatisfaction, burnout and estrangement, the later now being called ‘alienation’ in the US. Part 2 explores the nature of healthcare labour and changing patterns of work in the NHS, as possible drivers of dissatisfaction, burnout and alienation. In Part 3, we propose a testable, hypothetical model linking the three states. Finally, in Part 4, we explore the possible implications of the model for NHS leaders, trade unions and professional organisations.

Throughout this discussion paper, we use ‘estrangement’ and ‘alienation’ interchangeably, and refer to ‘practitioners’ or ‘health professionals’ when more than one discipline appears to experience job dissatisfaction, burnout and alienation for similar reasons.

Part 1: job dissatisfaction, burnout and alienation

Job dissatisfaction

Light ¹⁵ argues that medicine has become less satisfying because several trends interact to undermine the style of clinical practice in which practitioners were trained. Diagnostic tools have become more ‘fine-grained’; the more practitioners look, the more problems they find, but without necessarily being able to do anything about them. Other professionals (and some patients) challenge medical decision-making, often arguing about evidence of treatment effectiveness. One reason for working in multidisciplinary teams is to harness that challenge productively, to achieve the most appropriate therapy for the individual patient, but this can be blocked by unresolved tensions among group members. More patients are older and more complicated, and hospital services are ill-prepared for large and growing numbers of complex, frail people. Finally, healthcare progress has depended on close working between professionals and commercial drug and medical devices industries – the ‘medical-industrial complex’. This relationship carries tensions, because medication or devices may cause damage as well as offer gains to individual patients.

About one in three doctors report job dissatisfaction, and it is seen as a threat to clinical decision-making and interpersonal care. ¹⁶ However, there is little evidence to support specific claims of harm while there are signs (particularly clear in UK general practice) that job dissatisfaction is reversible. Nonetheless, job dissatisfaction may stimulate the idea of moving jobs or employers (perhaps into the private sector) or emphasise the desirability of moving or increase the pressure to leave. For example, NHS junior doctors aggrieved by the 2016 dispute over contracts may envy the relatively comfortable conditions their peers work under in Australia and opt to migrate; even a small number of migrants can deplete NHS training programmes.

Job satisfaction among nurses has different features, being defined as an affective reaction to work among practitioners who compare actual outcomes with those that are desired, expected and deserved (in the practitioner’s view). ¹⁷ Job satisfaction defined in this way has three components: autonomy; interpersonal work relationships; and patient care. Autonomy is related to scope of practice, interprofessional teamworking, and support from peers and management. Interpersonal work relationships include both nurse–nurse communication and the quality of nurse–doctor joint working. Patient care includes good relationships between nurse and patient, subjective feelings of doing a worthwhile job, positive feedback and praise and the pleasure of seeing ill people become well.

On the other hand, bullying (‘horizontal violence’ in the US) is associated with job dissatisfaction among nurses, but its impact is reduced where peer relationships are good ¹⁸ while lack of peer support encourages nurses to leave their current job. ¹⁹ A study of advanced nurse practitioners and advanced midwife practitioners in the Irish Republic ²⁰ suggested that interprofessional collegial relationships and managerial recognition of their role were associated with job satisfaction.

Burnout

Three feelings are considered features of burnout ²¹ :

Feeling emotionally ‘spent’ – emotional exhaustion;

Displaying a detached attitude towards others, whether patients or colleagues – depersonalisation, sometimes called ‘cynicism’;

Low sense of work efficacy – diminished personal accomplishment.

The opposite of burnout is ‘engagement’, a positive, fulfilling state of mind that is typified by vigour, dedication and absorption.^22,23 These feelings may be experienced at different levels of intensity. The contented practitioner is likely to be low on all three (Engaged) while the practitioner who is high on all three has burnout. In between these extremes, it is possible to be overextended (high on exhaustion but not on the other features), disengaged (experiencing mostly depersonalisation/cynicism) and ineffective (mostly low efficacy). Burnout appears to be inversely associated with empathy. ²⁴ Depersonalisation of colleagues or patients (cynicism) appears to be the most damaging of the three feelings. ¹⁰

Clinicians with burnout may report sub-optimal care and patient safety incidents, although patient care provided by practitioners with burnout does not appear impaired to patients. ¹⁷ A systematic review and meta-analysis of mostly cross-sectional studies of low to moderate quality, and with a high level of heterogeneity, ²⁵ showed that self-reported patient safety incidents were significantly associated with burnout symptoms, but the association between physician burnout and system-recorded safety incidents was not statistically significant. Patient safety incidents and suboptimal patient care were assessed based on physician self-reports across the majority of the studies. One possible explanation for this pattern is that those with burn-out are more self-critical, honest and likely to report having made errors even when they have not. Lawson ²⁶ argues strongly that researchers, medical journals and medical leaders should not infer that burnout is associated with, let alone a meaningful cause of, medical errors or preventable adverse events. The view that too much is at stake with burnout and that urgent action is needed, even if knowledge is imperfect, ²⁷ is challenged by Schwenk and Gold, who argue that action is being taken for a symptom without any actual understanding of its pathophysiology, origins, consequences and effective treatments. ²⁸

This is an important point that should make practitioners and health service managers pause for thought. Those experiencing burnout symptoms are unlikely to enjoy them, but they are not necessarily disabling in a practical, clinical sense, at least in the short term. This is not to say that there is no causal connection between burnout and patient safety, only that longitudinal studies are required to demonstrate it, and clarify its direction. A cross-sectional study of doctors and nurses in Swiss intensive care units ²⁹ showed a statistically significant association between emotional exhaustion and standardised mortality rates, but could not show whether higher patient death rates trigger staff burnout, or burnout in the practitioner increases the risk of patients dying.

After nearly 50 years of the study of burnout, there are many proposed solutions to it but little evidence of their effectiveness. ²⁸ Studies of burnout do not agree on its precise definition, so it is difficult to see whether it is related to the job (like oncology), the practitioners’ aptitudes (like emotional skills) or their characteristics (women more prone to burnout). Nevertheless, there are hints about the interaction of factors effecting burnout. Doctors most at risk are (perhaps predictably) younger women working longer hours and experiencing work-home conflicts, ³⁰ and they rather than their patients experience adverse health outcomes. ³¹

Despite the failure of occupational health services to find a ‘cure’ for it, burnout still matters. Its long-term impact is not known, it may progress to alienation (as we argue below) and it can appear early in practitioners’ careers. Burnout occurs in a minority of medical undergraduates, who have had little exposure to their future work role, suggesting that there may be characteristics that make individuals vulnerable to burnout. ³² For example, burnout may occur more often in individuals with narcissistic personalities, and in those with depression, ³³ but the size of the risk is small – 3.5% of the total burnout scores in these studies were attributable to narcissism and 3.6% to depression.

The work environment and processes seem to have more influence on burnout than individuals’ characteristics. One researcher, Montgomery, ³⁴ argues that burnout is inevitable because maladaptive habits acquired during training are reinforced by experience of working in the pressured environment of a modern health service. The problem, as Montgomery sees it, is that practitioners (particularly medical ones) are trained to be individual clinicians, not team members and team players, and believe (wrongly) that the health service is there to support their autonomous work. The reality is the opposite, team working is essential and the practitioner is usually part of a larger work unit, be it the palliative care team, operating theatre staff, group practice, out patient clinic or hospital ward.

Alienation

Alienation – estrangement from patient care, often attributed to the industrialisation of practice ³⁵ – is associated with burnout. The traditional 19th century view of alienation as an objective and multi-faceted feature of the worker’s relationship to work has been challenged both by the French sociologist Lefebvre ³⁶ and by contemporary US authors like McKinlay and Marceau, ¹⁶ Light ¹⁵ and Dzeng. ³⁵ This challenge has two parts. There can be many sources of alienation, according to Lefebvre, but they produce a subjective and reversible state, and ‘dis-alienation’ can also occur. And, while alienated practitioners may feel powerless, isolated and normless, and experience their work as meaningless, it is this latter feeling that defines alienation as a unidimensional construct of estrangement. ³⁷

As an example of the diversity of alienating processes, doctors in training in the US and in the UK display alienation, but for different reasons. US doctors struggle with forceful consumers who want ineffectual or futile treatments, while British doctors attribute their alienation to the bureaucratic drive for greater efficiency and higher productivity at the expense of the practitioner and patient. ³⁵ Nurses in Turkey, on the other hand, experiencing lack of supportive work relationships, report poorer clinical performance, especially if they are alienated. ³⁸ Whatever the differences, alienation does seem to be damaging, eroding commitment to the job, provoking counter-productive behaviours (like frequent sickness absence, provoking conflicts with colleagues) and inducing self-harm (through alcohol/substance misuse). In this sense, alienation is ‘worse’ than job dissatisfaction and burnout, in that it is more damaging.

Light ⁷ proposes mechanisms to promote dis-alienation, like developing a shared purpose in improving patient care, trusting leaders, enacting collegiality, receiving a fair income and seeing a sustainable future. In our view, these proposed solutions to alienation point to two fundamental drivers of job dissatisfaction, burnout and estrangement – the nature of healthcare labour and its organisation.

Part 2: the nature of healthcare labour

The scale of staff shortages is clear, but the nature of NHS work is less easily described. All healthcare practitioners carry out both ‘immaterial’ and ‘emotional’ forms of labour, which have consequences for their job satisfaction, psychological state and job commitment.

Immaterial labour

Much of the work done by nurses, doctors and other health professionals is ‘hands on’ (examining, ordering investigations, operating, dressing wounds) and face-to face (listening, interpreting, mediating, breaking bad news), but all such physical effort depends on immaterial labour. ³⁹ This requires judgement and discernment, openness of mind, and the ability to synthesise formal scientific knowledge with experiential knowledge. Such immaterial work is demanding and stressful, made more so by its content – experiences of illness, fear, pain and death. The stresses of immaterial labour are intrinsic to the work of nursing, medicine and other disciplines. Practitioners may become more skilled at all of the tasks of immaterial labour, but the tasks remain hard.

Emotional labour

This is the work (effort, planning, control) required to express organisationally desired emotions during interpersonal transactions. ⁴⁰ At its most extreme, this form of labour insists on the rigid regulation of insincere, relatively one-note emotions (‘Have a nice day!’), and the stresses that flow from them. ⁴¹

Health professionals are less likely than, say, call-handlers, to experience extreme cognitive dissonance through their emotional labour, and may even be able to modulate their emotions so that they can express joy at the birth of a baby, anxiety at a cancer diagnosis or sadness at a death. ⁴² The important point about emotional labour is that the practitioner has to understand and work with the patient’s emotions, and learn which of their own emotions should be hidden from view and which should be manifested in this therapeutic process. Those who learn how to modulate their emotional responses acquire ‘deep acting’ skills, while the less emotionally flexible develop a ‘surface acting’ approach.

Deep actors report job satisfaction because emotional labour creates positive outcomes, not just stress. Their co-workers see them as confident, empathic, adaptable and good at resolving conflicts; their effective performances are daily assets in wards, clinics, ambulances and operating theatres. ⁴³ Surface actors, on the other hand, tend to suffer from the cognitive dissonance of emotional labour, which is expressed through work absence, job churn, failure in leadership roles and burnout. ²⁸ The question for practitioners and managers is can deep acting be taught? This is difficult to answer, but we do know that education, role-play and debriefing can reduce job strain among nurses in the highly emotional environment of the intensive care unit. ⁴⁴

The organisation of healthcare work

England’s NHS has no monopoly of health service reorganisation and reform, any more than it does of job dissatisfaction, burnout or work alienation, which are encountered in almost all healthcare systems. In the late 20th century, the long-term time horizons of growing economies encouraged belief in life-long employment in an organisation (like the NHS) that would outlive the worker. ⁴⁵ Establishing a bearable working relationship between those who sold emotional and immaterial labour and those who paid for it then made sense in the early decades of the NHS.

This understanding may no longer be useful, to either party, in the less stable environment of portfolio careers. Those who train in nursing or medicine may not seek long careers in either, or may move in and out of work, sometimes in different organisations or different countries. Bearable working relationships may no longer matter. Frequent NHS re-organisations can force practitioners to apply for their own jobs, while top-down campaigns divert staff away from current tasks to work on politically driven new projects.

Part 3: a model of job dissatisfaction, burnout and alienation

We propose a model of healthcare labour and its effects on practitioners, based on three assumptions. The first is that alienation is the consequence of job dissatisfaction that progresses to burnout (Figure 1). Not every practitioner who is dissatisfied with her job becomes burned out, however, and those with burnout do not automatically graduate to work alienation, so we hypothesise that there is an accumulation process within each state that leads to a qualitative change in that state; job dissatisfaction worsens, burnout intensifies, alienation deepens.

Figure 1.

Modelling job dissatisfaction, burnout and alienation. Subjective states are represented by boxes. Bi-directional arrows indicate reversibility of states. Grey shaded areas suggest some work-related triggers of change in subjective state.

The second is that all three states are reversible, which means that the most damaging outcome – alienation – is preventable, in principle, by attention to the sources of job dissatisfaction and burnout.

The third is that individual vulnerabilities play a small part in generating all three states, suggesting that routing vulnerable individuals away from stressful work environments might be beneficial, albeit for a minority.

This model of alienated labour in the NHS implies that alienation lies beneath the states of burnout and job dissatisfaction, and is hidden by them. Grumbling about arbitrary management, regulation or commissioning, about aggressive patients and families, or about unreasonable demands on time – all everyday occurrences in the NHS – may be seen as just job dissatisfaction unless questions are asked about emotional exhaustion, depersonalisation or loss of effectiveness. In the layer beneath burnout, the relevant questions would be about the meaning of work.

Part 4: undoing the damage

The reversibility of all three states should motivate management, professional organisations and trade unions to alter the meaning of work and mitigate its experience. As Cicolini et al. put it ⁴⁶ :

In the current context of the health care system that is under constant stress … health care managers have to consider the relationship between empowerment and organisational outcomes, and especially they have to focus on job satisfaction as a retention outcome.

Remedial actions can be taken at system level, at the level of the work unit, and with individuals.

At system level, Don Berwick, a senior US physician who admires the NHS, offers a manifesto which differs from the usual exhortations to integrate, collaborate and become patient-centred. ⁴⁷ His recommendations include stopping excessive measurement, reporting and auditing, abandoning complex financial incentives, reducing the focus on budgets but increasing attention to care quality, protecting civility and rejecting greed. These proposals will not reduce the emotional labour of clinical work, but they could reshape work experiences positively. Nonetheless, we should be aware that whilst improving the work climate can have a positive effect on job satisfaction and burnout, the effect can be enhanced by favouring strong professional commitment (engagement) and promoting intrinsic (key work motivators like autonomy and sense of accomplishment) rather than extrinsic work values (limited motivators like salary and career progression). ⁴⁸

At the work unit level, Cicolini et al. ⁴⁶ propose a model in which structural empowerment of nurse teams leads to psychological empowerment of individual nurses, with a resulting rise in job satisfaction. Structural empowerment occurs when practitioners receive information that is relevant to the task facing them, have resources (especially time) to do the job and are supported through feedback and guidance with opportunities to learn. This empowered environment allows practitioners to see their work as meaningful and effective, and enlarges their competence. The caveat here is that empowerment, when promoted by the management hierarchy, can be experienced as adding to work demands rather than making them more manageable. ⁴⁹

There may be scope to prevent burnout and alienation in vulnerable individuals by redirecting them away from work that requires emotional labour on a scale unsuited to them. Understanding alienation as a subjective experience acknowledges that some individuals may be vulnerable to the stresses that convert job dissatisfaction to burnout and burnout to alienation. Knowing what those vulnerabilities are could prompt offers of support and career guidance and might even influence selection for training. Individual vulnerabilities matter, but should not be overstated, for they have only a weak effect on the development of job dissatisfaction and burnout compared with the damaging features of the work environment.

Conclusions

We propose a hierarchical model of job dissatisfaction, burnout and alienation, all of which are reversible. Alienation, in its modern meaning of estrangement from meaningless labour, is the worst state because its outcomes are serious for individuals and health services. All states in the hierarchy can be induced by patient-related work, and by work organisation. Emotional and immaterial labour are the essence of healthcare practitioners’ work, and so cannot be escaped, but their impact can be ameliorated. The reversibility of all three states means that efforts to ameliorate them will centre on the re-organisation of work to optimise beneficial outcomes. While some individuals may be particularly vulnerable to the stresses of work, and need counselling and guidance, the primary task may be to alter those working environments that promote job dissatisfaction, burnout and alienation. We accept that our focus on the organisation of work excludes the impact of perceived under-remuneration of work; this requires further investigation. Similarly, we have not discussed sexual, gender or racial harassment as forms of bullying, and these behaviours need attention; so too do patient and family behaviour and expectations.