Neurodivergence – An Exploration of Challenges and Opportunities Within the United Kingdom's Clinical Academic Health and Care Professionals Workforce

Abstract

This article explores how neurodivergence and neurodiversity are understood in the clinical academic workplace of nurses, midwives, allied health professionals, health care scientists and pharmacists. We consider how neurodivergent people may behave or think differently to people who are not neurodivergent, and how inclusive and equitable academic cultures might be promoted.

Introduction

Neurodivergence and neurodiversity have become terms which are now more easily recognised and understood in the workplace. It could perhaps be argued that the term neurodiversity ought to apply to everyone because it encompasses the idea that we all interact with the world in different ways. This ‘world view’ acknowledges that there is no one way of thinking and behaving. Neurodivergent people are defined as a group who are not ‘neurotypical’ (Doyle, 2020). Neurodivergence can be categorised by diagnoses which include dyslexia, dyspraxia (developmental coordination disorder), dyscalculia, dysgraphia, hyperlexia, Meares–Irlen syndrome, autism spectrum disorder, attention deficit/hyperactivity disorder (ADHD), Tourette's, stammering, and obsessive-compulsive disorder (Exceptionalindividuals.com, Constantino, 2018; Doyle, 2020). Neurodivergent diagnoses may also overlap, for example 20–65% of neurodivergent people are both autistic and have ADHD (Leitner, 2014).

Clinical academic careers enable clinicians to combine clinical skill and insight with research (Baltruks & Callaghan, 2018, CATCH) to provide benefit for health and social care users (DoH, 2022; Whitty & Wood, 2021). This benefit is well documented (Boaz et al., 2015) and research active organisations are linked with better outcomes such as decreased mortality (Jonker & Fisher, 2018; Majumdar et al., 2008). Research can stimulate innovation, creative thinking, cohesive enthusiastic teams and positive organisational culture (Denegri et al. 2015; DHSC 2022). Globally it is estimated that 15–20% of the population are neurodivergent and this can be broken down into distinct neurodivergent categories, for example, in the United Kingdom 1% of the population are thought to be autistic (NICE, 2024). Thus, while the authors cannot report the prevalence of neurodivergence within the United Kingdom's clinical academic health and care professionals’ (HCP) workforce, one could expect the prevalence to broadly reflect the global epidemiological picture. It is hoped that this is the case, as ‘a diverse population is better served by a diverse workforce that has had similar experiences and understands their needs’ (GMC, 2019).

In this article, the authors argue that people who identify as being neurodivergent may encounter specific opportunities and challenges within the United Kingdom's HCPs clinical academic working environment. We use the term HCPs to encapsulate nursing, midwifery, allied health professionals, healthcare scientists and pharmacists (NIHR, 2024). Two of the authors (ES and SS) present their own experiences as case studies to explore how a speech and language therapist with ADHD and a physiotherapist with dyslexia were able to move from the point of diagnosis towards being fully embedded within a clinical academic career workplan.

What features of clinical academic work might affect how neurodivergent people operate in the workplace?

Clinical academics are required to: (i) balance clinical and academic (research and teaching) work, (ii) lead and produce research outputs and (iii) deal with repeated rejection and failure. This requires a number of character traits such as determination, resilience, risk taking (King et al., 2023) and creativity (Newington et al., 2021). The clinical academic environment is characterised by high demand and at times intense pressure for HCPs (King et al., 2023) and doctors alike (Nassar et al., 2019).

Some characteristics of neurodivergent people could be well aligned to meet the specific pressures of clinical academia. For example, neurodivergent people can be extremely creative, hyper-focussed, and attentive to detail (McDowall et al., 2023) and this intense passion and focus has been aligned with success in academia (although of course, neurodivergent scholars could also achieve success without any intense interest) (Mellifont, 2021). While the abilities of a neurodivergent person may line up nicely with the demands of academia, there may also be challenges. For example, the workload of a clinical academic involves intense periods of writing (and often a high e-mail load) which can be stressful if accurate reading and writing requires significantly higher effort (Alexander, 2021). Clinical academics are needed to present to large audiences at busy conferences (Mellifont, 2021) where quiet spaces may not be easy to find, and they may work in shared office spaces where noise cancelling headphones may not be commonly used.

There is now a plethora of work to support inclusion and adjustments for neurodivergent academic staff (Brown, 2021), and healthcare staff. Within the National Health Service (NHS), the extent to which organisations are integrating disability friendly policies and practices into their workplaces is monitored and measured through the Workforce Disability Equality Standard. In the United Kingdom, across many HCP professional groups, guidance on supporting the neurodiverse workforce has been published – for example – Neurodiversity Guidance, Peer Support Service, Royal College of Nursing. However, it is also suggested that the agenda for inclusion (and recognising the capabilities and strengths of neurodivergent healthcare staff), is still growing in the United Kingdom (Granger et al., 2023) and elsewhere in the world. In Sweden (Hedlund & Jordal, 2024) and New Zealand (Hughes et al., 2021 cited in Taylor et al. 2024), it is also noted that healthcare systems may not be set up to fully optimise the abilities and talent of their neurodivergent staff.

The U.K. clinical academic work environment is also complicated by the issue that career progression for non-medical HCPs, is operationalised differently to their colleagues who trained as doctors and dentists. Next, we describe these differences to better contextualise the challenges and opportunities faced by HCP clinical academics in the United Kingdom.

Why is the clinical academic space for HCPs in the United Kingdom different to medically qualified staff?

Firstly, while there are clear drives to implement clinical academic careers for all HCPs challenges in defining exactly what a clinical academic is and being able to embed clinical academic career pathways for HCPs persist (Newington et al., 2022; Palmer et al., 2023). Career choices can look different for HCPs (nurses, midwives, allied health professionals, healthcare scientists and pharmacists) when they are compared to doctors and dentists: medical staff tend to be encouraged into clinical academia earlier in their careers, and there is a need to better embed research time and activity into HCP clinical academic job descriptions (Trusson et al., 2021). Yet, while U.K. HCP clinical academics do face an uncertain time ahead while career paths develop (Palmer et al., 2023), it could perhaps be a unique opportunity for neurodivergent staff – who ‘see the world differently’ – to use unique insights from their own experiences to contribute towards shaping and defining an evolving and emerging new HCP clinical academic landscape.

Secondly, HCPs may not have an easily identified mentor or senior to aspire to because traditionally, healthcare research has been associated with medically trained professionals. In 2016, 4.2% of U.K. medically qualified staff were employed as clinical academic professors, readers or lecturers in U.K. medical schools (Medical School Council, 2017), yet the goal for nurses, midwives and allied health professionals is for 1% of the workforce to achieve a clinical academic career by 2030 (Newington et al., 2023).

What are the main challenges and opportunities for non-medical professionals who are clinical academics?

A neurodivergent person may behave or think differently to people who are neurotypical. These differences are sometimes beneficial to individuals and their workplaces and sometimes detrimental. In our opinion, these differences can be detrimental for neurodivergent clinical academic HCPs when they experience a tension between wanting to use their unique traits or abilities (such as hyper-focus) to good effect, but also feeling pressured to lean towards ‘typicality’ and ableism. This is because neurodivergent people who are trying to conform can experience exhaustion, anxiety and burnout (Cage & Troxell-Whitman, 2019; Miller et al., 2021). Mental health for neurodivergent healthcare staff can also be adversely affected when workplace adjustments are requested but not received (Shaw et al., 2023), or when a person perceives rejection by others (Johnson & Ahluwalia, 2024). Burnout could perhaps be exemplified in the clinical academic setting which is already characterised by high pressure (King et al., 2023), the burden of decision making around disclosing a neurodivergent diagnosis in academia (Mellifont, 2023; Sarchet, 2024) or clinical practice (Shaw et al., 2023), and the problem that work environments are often structured according to a neurotypical world view (Sonuga-Barke & Thapar, 2021).

The mental health of healthcare workers has long been recognised to impact (i) ability to provide safe and effective care (Johnson et al., 2018) and (ii) workforce retention (Koinis et al., 2015). Consequently, the NHS support for staff such as rapid access to counselling, and within the clinical academic space awareness of mental health is rising with projects such as the #100 voices campaign (#100voices, zjayres). Problems in implementing support may persist due to under-reporting of both mental health problems and neurodiversity (as neurodiverse people do not consistently identify as having a long-term health condition therefore published prevalence is likely to underestimate the true population) (Buckland et al., 2024), which makes it difficult to plan infrastructure. Yet, the overall response to the challenge of stress and burn-out should be well supported by the NHS Workforce Disability Equality Standard, which as part of the wider NHS long-term workforce plan, was put in place in 2023 to support neurodivergent healthcare staff to enact their qualities. Both national policy – and the local organisational infrastructure which embed national policy – are designed to foster a culture of inclusion and belonging, with the goal of recruiting from the widest possible talent pool (NHS people plan 2020/21). Responsibility will rest on the shoulders of employing organisations to ensure that the systems within those organisations are suited to provide appropriate and meaningful support.

One of the key opportunities for aspirant HCPs who identify as being neurodivergent is that the appetite to support and grow clinical academic careers is strong. The inherent strengths of clinical academic careers for Nurses, Midwives, Allied Health Professionals, Pharmacists and Health Care Scientists are recognised by the Chief Midwifery Officer for England's strategic plan for research (NHS, 2023), the Chief Nursing Officers Strategic Plan for Research in England (NHS, 2021), Health Education England's (HEE) Allied Health Professions’ Research and Innovation strategy for England (HEE, 2022; HEE's Clinical Academic Careers Framework, 2018). These documents encourage research to be ‘normalised’ and embedded as part of usual practice for all health care professionals and they highlight a need to achieve a greater diversity of expertise in research and leadership.

Workplace adjustment for neurodiverse staff has also received attention. Generic guidance on supporting staff has been issued by NHS Employers in December 2023 (https://www.nhsemployers.org/publications/making-workplace-adjustments-support-disabled-staff). Specific guidance on recruiting and retaining staff who may identify as being neurodivergent can also be located through NHS Employers (2021), though – to the authors knowledge – there is no guidance specifically pertaining to the recruitment and retention of clinical academic health and social care staff who identify as neurodivergent.

Case Studies

Next, to give context and to ‘frame’ the presentation of the literature and arguments made above, we present two short reflections of HCPs who share their own experiences of identifying as neurodivergent and how they embarked (and remained) on a clinical academic career trajectory.

Case study 1 – Emma Sutton: Physiotherapist and Academic

I readily relate to many of the challenges (and opportunities) encountered by the HCP clinical academic workforce. First, I was diagnosed late in life, in my third decade, around the same time as entering the clinical academic workforce. I wrestled with my own acceptance of being labelled with the diagnosis of dyslexia, and at the same time (in 2013) I needed to put strenuous effort into crafting my own clinical academic pathway. I still worry about the deficit-based view of neurodiversity. I avoid ticking the ‘disabled’ box on forms because (i) I worry about stigma which may be attached to my diagnosis and (ii) I don’t see my neurodiversity as a disability. I relate to the effort of needing to ‘fit’ and the need to ‘camouflage’ my ‘deficits’, can feel heightened within my academic work setting, when I need to excel in high level writing and oral presentation. This leads to stress and exhaustion.

Second, I have experienced feeling ‘different’ throughout my clinical, and my later clinical-academic career. I am sometimes not able to ‘word-find’ as readily as my colleagues, and my colleagues seem much more able to rapidly send completely grammatically correct e-mails. My e mails often need to be read and re-read before sending (which takes a lot of time) to avoid the embarrassment of typos when they are being set out to high performing professors and senior leaders who expect the best. I would usually portray the message much better by speaking. I find that I pick up the phone more often, to overcome the e-mail ‘jitters’ that disrupt my working life. Perhaps, – because I feel different – I deliberately seek out others who are similarly not ‘neurotypical’ – by joining the staff neurodiversity network, for example.

I consider myself to possess many of the traits described by King et al. (2023) – I have faced rejection and failure many times (which is commonplace in academic work) and I have developed resilience and determination to keep going. This is not necessarily specific to my neurodivergent diagnosis but many other traits probably could be. For example, my tendency to hyper focus, and the way in which I have responded to a fear of stigma – by trying to achieve ‘hypercompetence’ by saying ‘yes’ and taking on extra tasks. Embarking on a clinical academic career has also illuminated to me that I may not fit neatly into one box. For instance, I can find it exceptionally frustrating trying to understand something which is not explicitly stated (making inferences) – which is perhaps why I am drawn to research in the first place. I also struggle when ambiguous language is used (metaphor or humour – for example) and I can tend to take a given conversation quite ‘literally’, perhaps because of these difficulties in interpreting nuances.

Now that I am more fully embedded in a senior clinical academic role I have been able to temper the pressure I previously felt to live up to a ‘superhuman’ productivity rate to match my neurotypical colleagues. I have completed an access to work application and now engage with AI in applications such as mind view and claro read to overcome my specific challenges in reading and writing. I also disclose more, and have generally had positive responses from both students and staff in clinical and academic settings.

What then needs to happen going forwards? I wonder how are the abilities of the neurodiverse workforce distinct or different and how could they be better utilised? How could the working lives of neurodivergent people who are clinical academics be further improved? In clinical academia, elevator pitches are vital – we are required to pitch ourselves with elegance and poise in order to engage professionally with other researchers, to disseminate our fundings, to obtain funding, to drive forwards a research agenda for the benefit of patients. How might these pitches be affected by the self-image and self-belief of a neurodivergent person? How much work is being done at the ‘grass roots’ to encourage people who identify as ‘neurodivergent’ to enter clinical-academic careers? There is a call for medical schools to adopt a neurodiversity affirmative approach to support the inclusion and training of autistic students (Shaw et al., 2022). NHS England also supports and advocates for neurodivergent nursing and AHP students, enhancing their learning experiences through Sharing Student Healthcare Initiative for Neurodiversity and Equity (NHS England, 2023).

So, while I feel there are difficulties for me, and others in this very specific working space of clinical-academia, I can see glimmers of light. NHS staff networks are thriving and a great source of resources and peer support. There are important steps forward in a movement of ‘social justice’ which has started at the ‘grass roots’ to engage more early career clinical academics to take those first steps and to celebrate their unique selling points.

Case study 2 – Steph Scott: Speech and Language Therapist and NIHR Pre-doctoral Clinical Academic Fellow

It has become clearer over the years which parts of my neurofunction are ‘plastic’ and which are divergent and ‘fixed’. The journey travelled reveals and influences how our individual brains learn, adapt, and cope. For many neurodivergent people growing up in a largely ableist society, this can take a long time and present numerous challenges along the way. As a teenager I was aware that my approach to learning was different to my peers, and one that didn’t respond quite so well to formal education. It didn’t occur to me or my family or my teachers that this might be due to a neurological difference. I just wasn’t very academic. This distortion of my truth inflicted considerable damage on my developing self-esteem, self-identity and self-confidence, and as such influenced and perhaps limited my life choices. Not that this matters now. I am deeply satisfied with the way my life has panned out. The challenges have equipped me with excellent transferable skills such as self-awareness, compassion, insight and emotional resilience. Equally, I feel that my narrative is much less likely to be repeated in British society as we become increasingly aware, accepting and supportive of such differences. Young neurodivergent people will understand themselves better and sooner, with the opportunity to bring their unique perspective to the world, to actualise professionally and personally, with hopefully little damage to the way they feel about themselves along the way.

I received a diagnosis of ADHD two years ago. Decades of masking the associated challenges meant that it was really only me who noticed the difference when I started taking medication to open the affected neural pathways. Initially I felt like I’d been given hearing aids. What others said to me landed like never before. Then there were improvements to my organisation, planning and productivity. It was like my brain could finally do what it was capable of. But the most potent outcome of taking medication grew slower than the rest: I found I was no longer worrying. About what I might have missed, forgotten to do, didn’t hear, might have already asked. I was ‘awake’, even at times when I wasn’t gripped, and that was indescribably liberating.

By the time of diagnosis and treatment I had already completed the WM clinical academic internship and successfully applied for the HEE/NIHR Pre-doctoral Clinical Academic Fellowship. My unmedicated neurodivergent brain had, in a roundabout way, found its way into clinical academia, something it had aspired to do for many years. My passion for my patients, my research topic and associated hyper-focus for anything related, is largely responsible for this. Aided by an ability to see patterns and connections in the world around me that I filter through my obscure and abstract creative inclinations. A combination that I have come to value in myself, and that I intend to use for the benefit of my patients and others like them.

There is no doubt that medication for ADHD has improved my approach to my work and my ability to focus at times when I’m less interested. There's less backtracking now and crucially less fear. But while I’m certain medication has enhanced the journey for me, I do not believe it has changed the destination. I feel that the uniqueness of my thought process, my hyper-focus and my energetic approach to life was already en route to a successful clinical academic career. I just think that the passage will be smoother now.

Clinical academia needs individuals who can imagine and invent. Who can offer unique perspectives and alternative approaches to problem-solving. Who are accustomed to and have experience of overcoming challenge. Who better for the field of clinical academics than those with divergent thought, excellent coping skills and are by the nature of their existence always looking for the answer?

Conclusions

To our knowledge this is the first peer reviewed case study of shared personal experience of neurodivergence and what this looks like within sometimes highly pressured clinical academic environment.

This article provides two take-home messages:

People who identify as neurodivergent should be able to enact their qualities to benefit the workplace as supported by the Workforce Disability Equality Standard.

Healthcare organisations committed to fostering the culture that research is everybody's business should provide appropriate and meaningful support to staff members wishing to pursue a clinical academic career.