🎙SUBSCRIBE HERE

Full transcript below – or watch as a video with subtitles.

Burnout is a really hot topic in healthcare.

Every day there are new reports about NHS staff hitting higher and higher levels of burnout.

But for a term that is used so much, how many of us know exactly what it is? And how can we begin to solve the issue?

In this episode Dr. Julie Highfield – a Consultant Clinical Psychologist in adult and pediatric critical care, and National Wellbeing Director for the Intensive Care Society – shares her expertise on the topic.

You can connect with Julie on social media @DrJulie_H

Books/chapters written by Julie:

• Organisations and Leadership during Covid-19: Studies using Systems Leadership Theory
• Psychological Staff Support in Healthcare
• Critical Care Psychology and Rehabilitation: Principles and Practice

See also the wellbeing work of the Intensive Care Society.

I’d love to connect with you so come and find me on LinkedIn, Twitter or Facebook.

Sign up to my weekly newsletter here to get updates about the podcast as well as psychology tips and insights direct to your inbox.

Follow and subscribe so you don’t miss an episode!

Transcript

Dr. Paula Redmond: Today I’m joined by Dr. Julie Highfield, who is a consultant, clinical psychologist in adult and pediatric critical care, and she’s also the National Wellbeing Director for the Intensive Care Society. Welcome, Julie. It’s really nice to have you here.

Dr. Julie Highfield: Lovely to be here. Thank you.

Dr. Paula Redmond: I really wanted to talk to you about burnout today. It’s a topic that has been, I think, on all our minds. It’s had a lot of attention, a lot of press recently, especially in the last couple of years, but I think it’s often a word that we don’t fully understand. It’s used in lots of different ways to mean lots of different things and I just want to get a really good sense of what it means, what it is, how we can recognize it and what we can do about it.

Maybe we can start with asking you what burnout is.

Dr. Julie Highfield: Okay. No pressure.

[laughter]

I completely agree with you. I think it’s often misconstrued, so we have to think about the three elements of burnout together. That chronic state of emotional exhaustion, so that’s element one. Feeling disconnected from the work or cynical, is element two, along with that feeling of getting nowhere, so that not really achieving much at work. All of those three things together are what constitutes burnout syndrome and that’s the really important thing. It’s syndrome, it’s not a diagnosis, it’s a cluster of symptoms that occur together.

It just made it into ICD 11, actually. I think the other thing it’s importantly recognized as not a mental health condition, but a work-based phenomenon. The more recent researchers, Christina Maslach being the key one, has really pushed that it’s an organizational phenomenon, rather than an individual phenomenon, but I think so much of what we hear and talk about is very much on that individual case by case basis, rather than recognizing, actually this is something that happens in clusters of people.

Dr. Paula Redmond: We’ve mentioned that it can be something that is misconstrued or misunderstood, what have you found have been the most common misunderstandings around burnout?

Dr. Julie Highfield: I’m going to give myself as an example here today. Here I am, last day before two weeks annual leave, and I’m at my peak exhaustion, I would say. It would be really easy for me in casual conversation to say, “Oh, I’m so burnt out.” In casual conversation people say, “Oh, I’m so depressed,” but actually what I mean is, I’m tired actually. It’s time for a break. It’s time to recharge the batteries. Do I still care about my job? Yes, I love it. I love my job. Do I still feel connected emotionally to my job? Yes, absolutely.

I go up and down, but I still very much feel connected to the work. There are days where I achieving something is a challenge, but it still feels like there’s always the win. In those terms, actually all I really have is the emotional exhaustion, which just says, “I’m tired and I’m in need of a break and a sit back and a rest.”

I often come across people in that position and I ask them, “But how do you feel about your job? Do you still love it? Do you still get something from it? Do you still feel like you’re getting somewhere?” That’s actually really useful because I think particularly the people I work with are not psychologically trained. They’re often nurses, doctors, and acute settings and they’re used to diagnostic labels. They hear this stuff in the press and in Facebook, memes and Twitter and all those sorts of social media, and they’re worried is that me, do I have this diagnosis? I think it’s quite often really, really helpful to help break it down with people and say, actually, no, you’re emotionally exhausted or you are tired.

Different side of it that I have to say, I tend to see the exhaustion more in nurses. In doctors, I tend to see the more disconnection. Actually, it’s really important to recognize the difference between burnout and rust out, actually and I think clinical psychologists are dabbling quite a lot in the area of workplace wellbeing. I’m there too, and actually it was an organizational psychologist that taught me that concept. It’s really well known in organizational psychology.

That rust out is basically, my job’s just not stretching me anymore. I’m a bit bored, I’m a bit disinterested. Actually, that’s a really important thing that a lot of people will get to when they’ve got everything they can get out of their job and so that sense of not achieving and that sense of disconnection is in fact, actually, I’m ready for the next challenge, rather than their unwell or struggling with burnout.

Dr. Paula Redmond: Oh, that’s a really nice distinction. Within those three parts of burnout, and you mentioned there that you see nurses experiencing more emotional exhaustion, doctors might be the more disconnected, I guess, is there a sense that people might have a profile within those three parts, that for some people it might be they might have features of each, but they might have more of one than the other?

Dr. Julie Highfield: Yes. This is part of a study that I conducted within Intensive Care Society in 2019. Actually, we’ve got a paper out on exactly that, obviously, within the area of critical care, but I think you can see the findings expanding to other areas. What we found were that allied health professionals and nurses were higher on the emotional exhaustion, whereas doctors were higher on the disconnection dissatisfaction.

What’s interesting is Maslach’s research says that those are the two most important components. That actually, the sense of achievement is almost like an independent factor that runs alongside.

Certainly, thinking about that profile while actually you think about the nature of the work of a doctor making difficult decisions, potentially breaking bad news, potentially withdrawing life-sustaining treatment, et cetera, those things. Actually, if they’re too emotionally connected to the work that they do, it’s quite damaging. You can see that at one point, actually, a little disconnection from the work is actually quite helpful. It’s just when it tips to the other side. That’s kind of links to the whole intelligent kindness literature, which would be a really good thing to talk about in a bit.

The emotional exhaustion side in terms of nurses where actually, you think doctors can step away from the bedside, nurses typically in Intensive Care, they’re at the end of the bedside, 1 to 1-12 hour shifts.

There’s really interesting stuff from Jill Maben that says, fatigue kicks in at eight hours for nurses, so that they spend four hours of their shift, so what a third of their shift in mini emotional exhaustion, if you like, a mini compassion fatigue. You think it’s that almost inevitable because of the way we set up shifts?

Allied health professionals are somewhere in between. They can step in and out, but they tend to be more present. You look at other areas, wards where you haven’t got the same intensity of ratios, but it’s still the case that nurses and allied health professionals are forever present, doctors step in, step out. It’s almost something about the nature of the work lends itself to which part of burnout might be emphasized.

Dr. Paula Redmond: I also want to ask you about, you said burnout isn’t a mental health diagnosis. It’s understood as an organizational phenomenon, but where does that lie with mental health problems? Where are the edges between burnout and depression, anxiety and also trauma? I suppose, I wonder that sometimes people use that word and there isn’t specificity around what people mean, whether they are depressed or burnt out or burnt out, rather than depressed and whether actually, particularly I guess over the last couple of years, whether there’s a lot of trauma around and burnout is an easier thing to hang that on?

Dr. Julie Highfield: Yes, it’s a difficult one. Again, it’s that tendency to put a diagnostic label on it, rather than as you and I would want, to be more formulation driven and understanding the context, but I guess that is the nature of their setting. That they like that diagnostic shorthand. I think for me, I think about a couple of case examples in my head and typical profiles, as you say, what I find is that there’s a lot of people I’ve worked with that have been constantly on, if you like, they’ve worked hard, they’ve had to do more in the context of having less resource to give to each patient and family members. This is where a friend moral distress, or if it’s not really that friendly, but it comes in, in terms of that discrepancy between what they would like to provide and what they’re able to provide. That kind of gap in the middle, I think forces people with clinical integrity to work harder to fill that gap.

You think, “Okay, well, what are you doing there?” You’re actually pushing that emotional exhaustion, you’re giving, you’re giving, you’re giving. I think alongside that, although where I work in intensive care, is a high vicarious trauma environment. I think what I see is a lot of almost lacking space to process emotionally. Each thing that they see, they don’t necessarily have the catharsis to let it go because the next thing, and the next thing, and obviously in the pandemic, it’s next, next, next, next. It’s just high frequency really of the same thing, but things that they’re trained to do.

What you can have is almost that emotional blocking, and I think it’s the stuff of this is where almost the crossover between diagnostic labels, isn’t it? You think about that emotional avoidance that can happen and trying not to think that things pushing through and intruding. That would tick those diagnostic markers for trauma, but actually, what lies beneath it is that chronic state of being on all the time and chronic state of activation.

You can get anxiety or depression in the mix, depending on people’s personality baseline. For some people, that chronic state of on just then spreads, and it becomes those worrying thoughts, they start to think about what’s going on at home, et cetera. They’ve witnessed bad things, they extrapolate those bad things to their home life, versus someone who’s more perfectionistic, self-critical, actually, it will flatten their mood. There’s so much crossover.

I have to say, I work in a fairly medium-scale tertiary referral center hospital, and I went through everyone that has come to me over the last two years, and just looked at my one or two-word label for what they’ve been through. Only one or two of them, could I give that clear sense of, that’s definitely PTSD, that definitely fits in the realm of burnout. I think often, it just feels like a messy quagmire, really, and I think that’s what’s not helpful for staff.

Within it, I think that the sadness and the complexity is that actually, most staff are exhausted right now. Some of them are disconnecting from the work to protect themselves, so it’s almost like burnout is coping. Part of that disconnection interferes with good trauma processing because you’re trying to disconnect and care a little less, you don’t want to think about work outside of work.

For some people, instead of seeing that as a systemic failure in the NHS, they will point that arrow inwards. It will affect their mood, it will affect how they feel about themselves. Sometimes part of the work I do is to help them to not feel upset with themselves, but to recognize actually, that system failure, but the problem is, is that sort of our control, isn’t it? In many ways, it’s easier to bash yourself with a stick and improve yourself because the system is big and rusty, and a bit of a mess.

Dr. Paula Redmond: It’s really tricky working in that space, the workplace well-being or the work that I do, which is largely individual work, where you’re coming up against that all the time, that the causes of burnout are these big, systemic complex issues, that as individuals, we can’t change, but the impact is so personal. How we find ways of making sense of that that doesn’t cause more harm, but it’s in some way empowering, in order for people to keep going or decide not to, whatever is going to be most useful.

I wonder how you navigate that working within the organizations, in terms of that fine line between offering support and not. I don’t know, I struggle with the whole resilience thing because I think– not necessarily the idea of resilience, but the way it’s used to locate the problem within individuals and the solution within individuals.

Dr. Julie Highfield: It’s a tricky one. I too struggle with the word resilience. It’s not a bad word, but just like compassion, it ends up being almost a way of saying, “Well, you’re the problem. You need to be more resilient, you need to be more compassionate,” rather than how do we enable and harness your resilience? How will we have resilience system, also, how do we enable that compassionate system as well, et cetera, et cetera?

It’s hard. I think it’s always hard to have one foot in. I think the way I’ve managed myself over the years is to always have one foot out to try to position halfway in, halfway out because I think that the thing that was hardest for me at the peak of the pandemic, certainly, but I think it’s always there when you’re integral to a system, is the fact that you’re thinking, “Yes, I agree,” and also, somewhat, “Me too.”

It’s really, really hard not to then collude with some of that negativity, and almost the emotional contagion, that can happen because in an interesting way, someone comes to you and their words, and you think, “Gosh, that’s really helpful for me to hear that you feel like that,” which is one of those really, really hard things, I think, for any psychologist or anyone in that position of helping, alongside workers in that system.

In some ways, it would be nicer to be a bit more removed, I think, because you could act more independently. There’s always that pressure of keeping the system going, you know when you’ve got someone in front of you, and you think, “Ugh, there is no other best way for you to protect yourself, other than to make a change,” and that means to move.

I know in helping you to find the right way for you, actually, you have a knock-on effect on everyone else, and that is a constant pressure. I think the way I manage it, is to just walk it like a tightrope every day.

Dr. Paula Redmond: That’s certainly something that strikes me, I guess, working very much independently, in independent practice, that I have got that freedom that it does feel freeing to be able to really just think about what is right for this person, to think with them about that without those pressures. It’s tricky when thinking about that knock-on effect because I think that’s something that people feel a lot, since they know that if they step out, if they step back, the impact on their colleagues is significant and I think that keeps people going longer than they should. Sometimes, it’s very hard.

Dr. Julie Highfield: Then that’s partly what lends itself to being that kind of organizational phenomenon. It’s almost the ripple effect that goes through. I think there is something of what that chronic workload pressure, and then that lack of supportive resources. By that, I don’t mean nice places to go, et cetera, although that helps, but that lack of good leadership, lack of good training, inability to take a proper restorative break, et cetera. That constant no slack in the system is sort of unabled system, means that actually collectively, that’s why the burnout happens.

There is certainly something of there are others that have just that little bit more energy, just that slightly different style that energizes and keeps other people going and compensates a little bit. To me, I find that they’re the ones who are at most risk of true burnout because they try so hard and they pull everyone else with them, that actually, they do at their own expense.

I think that is a risk of integrated psychologist in the system, but that’s also a risk of a really good compassionate leader, et cetera, no matter what their profession. You can see that there is that knock-on team effect. Everyone’s trying together to manage this, and then individuals.

Ironically, I remember it was one of the first things that I learned when I stepped into the world of workplace wellbeing, and it was a talk from the UK health and safety exec psychologist. They said that there is evidence to prove that if you teach people self care strategies in certain organizations such as the NHS, they become aware of how toxic their workplace is and they do the ultimate self care, which is to leave. Teaching “resilience” leads to higher staff turnover. Fascinating, isn’t it?

There is something of, collectively we hang on in there together, but actually, it becomes each to their own, and that’s survival.

Dr. Paula Redmond: One of the things that I’ve noticed, and I want to check whether this is something you’ve come across, is that often people seek help at the point of– often they use the terms breaking down, getting very distressed. For example, in the car park, having arrived at work one day or leaving and feeling really overwhelmed and like something’s shifted. Often, it feels really tricky because the thing that happened that broke the camel’s back was like a small thing, just someone was a bit rude to them and not that this is a small thing, but the annual leave that they requested wasn’t approved or something. I

think people struggled too, when their response seems really out of proportion to this little event, but actually, we can see how that’s just the tip of the iceberg of a whole lot of things. I think there’s something initially that happens just to help people understand that and understand their response. Is that something you see?

Dr. Julie Highfield: Absolutely. It’s usually that one case, that one patient, that one negative interaction with a family or with a colleague, or as you say, something like annually leave or something like that, but it’s the tipping point, isn’t it? I think this is part of almost that chronic problem with burnout that builds over time. We think of trauma usually as incident related, whereas burnout is that toxic buildup in a way.

There is some evidence. The evidence around burnout is really interesting and slightly shaky, but there is some evidence that actually not being able to emotionally offload and process, is one of the predictive factors for burnout. You could see that actually, if you think of your example and I’ve got a fair few examples like that myself, is just those people who just build and build and build, and there’s no outlet and no let-up. Actually, all that building, each little block probably feels minor.

Dr. Paula Redmond: I’m wondering if to step back a bit and maybe reflect on the past few years and where we are now, I’m curious to hear your thoughts because I guess, for those of us who pre pandemic, we were aware of burnout and massive mental health thickness within the NHS and it was a big problem then. Then obviously, we’ve had the pandemic and enormous pressures that people are facing now. I’d just be interested to hear your reflections on the landscape of burnout over the last few years and where you think that’s going.

Dr. Julie Highfield: Pre-pandemic burnout was high. The work we’ve done in intensive care said prevalence rates around about 1 in 3, which is pretty high compared to the general population. I think what I have seen in broader NHS workers, is a pull out all the stops because we think it will be short term and we think this is important. We’re part of history, we’re doing the right thing. What I certainly saw, certainly in the first wave a little bit differently in the second wave, was a all hands on deck and absolutely just expend all of your energy. I think in many ways, people had no other outlets and felt that it was going to be short term, so they just thought, “Well, this is okay to do.”

You look at particular areas, ICU being one of those areas where lots of people joined in to help and someone described that to me as snow days. When you have a short term bad thing happen, but everyone just rallies and it’s that blitz mentality and we can do it. Actually, there was an awful lot of joy around, let’s not forget that we enjoyed being absolutely heroic during that time. I think many, many people did. I think probably the people who struggled the most were those people who were redeployed without choice. Actually, they’re the ones that often get forgotten about.

I think that those that chose to and those that were already trained to, felt like, “It’s my time to shine,” actually. What shifted was over time that social disintegration though, isn’t it? Because then everyone went back, 2nd wave, 3rd wave, no extra help. Actually, the attitude by the 3rd wave was, “Well you’ve coped, so what are you complaining about? Don’t understand that,” rather than continued gratitude.

You could see with the pull out all the stops, emotional exhaustion side of things, people would just war themselves out. Actually, what started to happen is almost this sense of the system doesn’t care that you did that. Where’s the gratitude? Where’s the thanks? People have gone from banging pots in the street to swearing at people in NHS.

I heard a story of the clapping in the A&E because someone actually managed to be triaged, that sarcastic clapping, if you like. Public attitudes have shifted towards the NHS, that sense of they’re exhausted and they now feel entitled. I think what then happens is that NHS staff then tap into that disconnection, where they feel like, “You know what? You don’t care, I don’t care. I’m going to just sit back. I’m going to work to rule, actually. I’m not going to innovate. I’m not going to go on that social. If you can’t be bothered, I can’t be bothered.”

Actually, and amongst all of this, the system is so under pressure and overwhelmed, especially A&Es right now, where how can you ever feel like you’re achieving something? It’s actually really hard. It’s almost like the landscape for the possibility of burnout has just grown and grown and in amongst all of that, people’s personal vulnerabilities towards depression and anxiety have been triggered, and then people have had traumatic experiences in amongst all of that.

Ultimately, the key thing I see, the depressing thing I see personally, is that the psychological contract of work has been broken for NHS staff. One of the predictive factors in burnout is reciprocity. If we give and we receive, that protects us from burnout. If we give and nothing comes back in return, we are more likely to experience burnout. That reciprocity that was implicit in the NHS is hard to grab, but that gratitude seems to be slipping.

Actually, it feels like to be kind to managers, executive level, et cetera, it feels like it’s not there for them either, actually. I don’t feel like they’re being the mean ones, I feel like if we were to think about in terms of compassion focused ideas, I think everyone is in threat mode and they’re just in their silos protecting their own. This is the thing that I’ve seen that’s worse within that, is that pro-social behavior is really on a knifes edge in the NHS right now. You have little glimmers of it and it’s joyful when you get it, but generally speaking, people are edgy with each other now.

I think a lot of people have checked out because of that broken psychological contract. It feels like this is not what I signed up for. I’m not getting that implicit reward anymore. I’m just going to either work to rule presentism and check out to protect myself, or as we seeing in their droves, leave.

Dr. Paula Redmond: As you were talking, this just come to mind, some of the senior managers I’ve worked with, which has been very enlightening because they talk about exactly the same staff, often being shouted at, being expected to just pull rabbits out of hats, and the creep of what’s being asked of them constant more and more and more. It seems small, but then when you look back, as you’ve said, it’s not what they signed up for and it’s impossible. It’s impossible, so they can’t feel good that they’ve achieved something because they’re being asked to impossible things and pitting them–

Sometimes teams, I think, get fractured and particularly at senior levels when it can be– it may not have many peers when departments or functions are then fighting each other for resources. It’s horrible.

Dr. Julie Highfield: It’s grim, isn’t it? Considering we’re in the provision of healthcare, often then we forget the care that, but they’re not also– out of kindness to people, there’s the inevitability of it as well. We function in teams if we know each other. The maximum number is thought to be around about 10 to 12 people, but the teams I know are teams of 25 with a leader and 11 teams of 25. Actually, there’s not really teams. That’s arbitrary. That’s just around functionality of doing appraisals and signing off annual leave.

There isn’t that true social connection and that social embeddedness and you are right. I think senior managers feel quite isolated. I think there’s a lot of kicking up as well, that happens towards managers as well, who are not supported in that position, but feel that sense of responsibility.

Dr. Paula Redmond: Julie, what can we do?

[laughter]

Thinking about what helps from an individual level, a team level and maybe an organizational level as well? Should we start with the individual maybe? What helped?

Dr. Julie Highfield: Trying to unpack it really. I think that there are some researchers that think the opposite to burnout is engagement. I often think to people, what reengages you? What reconnects you with what you do? When I’m talking to an individual, I’ll talk about things like their stress management, their emotional regulation, all of that outlet for that stress, but I’m also thinking about what’s coming in. What’s invigorating you, what’s connecting you?

I’m really thinking in terms of, if we can manage the emotional exhaustion through boundary setting, through taking time out to pacing, but actually, the more underlying problem is managing the connection, and reconnecting, rather than that disconnecting. I would talk to people about almost finding one thing each day that feels like this is why I do this job.

You think about their core purpose, what they enjoy about the job, why they do that job. That’s a really hard thing to do, but I think that’s the thing that they need to almost reshift their focus onto. There’s different ways of doing that through conversation, through keeping diaries, et cetera, but in essence, pay attention to the good stuff, the stuff that matters to you to feel a sense of being reconnected with the work and celebrate every moment of achieving something. Within that achieving something, it’s finding that gratitude for achieving something.

Sometimes that means that actually what they need to do, is go get some feedback, go talk to their coworkers, go talk to their team leader, see what could be forthcoming just to reinforce actually, you’re good at this job and you do do well, to help them feel reconnected with the work. That’s the main thing I do. What do you do?

Dr. Paula Redmond: For me, it comes back to these three Cs, compassion, connection and creativity, which is exactly, I guess, what you’ve been talking about. Their compassion of I’m looking after ourselves and supporting our needs and caring for what we’ve been through. Then the connection about, as you’ve said, reconnecting with work.

I often find that what’s also helpful is for people to connect with things outside of work because I think especially for health professionals, when your identity and your self-worth is so tied up with your job and then that just feels like it’s sucking your soul and there’s no way out to open up to other identities and other things that bring you joy and meaning in life.

Dr. Julie Highfield: I’d agree and I think that’s probably one of the things that really caused that counterbalance in the pandemic, in terms of where is my connection to my wider self? Actually, people thought there’s nothing else to do our work and the balance is tipped. I think a lot of what we’re seeing now, in terms of people changing the nature of their jobs is because they’re thinking, after everything we’ve been through work is not my priority anymore, so I think that’s a really good thing.

I guess for me, you are right in terms of that. I think almost that a driving factor towards burnout is overwork drive as well, so feeling like I do more. Coming back to those energetic people who keep others going, they’re the ones that seem the most vulnerable because they say, “Let’s try this, let’s do this,” and overwork and then almost check out as we reach peak capacity. Having things that meet that need for drive, but aren’t work-related where they might achieve outside of work.

Dr. Paula Redmond: That’s where I think creativity can play a really great role in meeting some of those needs, but connecting to other things and being able to rest, especially if you’re someone who is very driven, finding ways of being able to rest while still being active.

Dr. Julie Highfield: Active rest, yes. I use that phrase quite a bit. The people I work with and I find I’m the same, struggle to sit still. We don’t like the idea of relaxation or meditation or things like that, but love the idea of paddle boarding, cycling, DIY, gardening, but then feel that that’s bad. I have coined that phrase of active rest to help them feel that, almost permission, to that’s how you can unwind through activity. Also, I think that utility of movement and anything that’s complex in a visual-spatial way, we know that that really helps with trauma processing.

Dr. Paula Redmond: For me, I know I talk about this a lot, but knitting is a great example.

Dr. Julie Highfield: I’m terrible at knitting, so that wouldn’t work for me.

[laughter]

Dr. Paula Redmond: It’s not for everyone, but I think it has all of those elements in it of being able to connect to things that you love, people that you love. If you’re making something for someone, it can be very complex, but also helps you to rest and tune into what you need a bit.

Dr. Julie Highfield: Do you want to know what mine are? I cultivate succulents.

Dr. Paula Redmond: Oh wow. I can see beautiful plants behind you now, Dr. Julie Highfield.

Dr. Julie Highfield: Because I got into the research around different ways of trauma processing, I found really highly complex jigsaw, honestly. I’ve never been a jigsaw person, I’ve always thought it was a bit middle-aged. My husband bought me a couple of really complex jigsaws, not last Christmas, the Christmas before and complex Lego as well, actually, this pattern by Lego. Just incredible how you can absorb, but also it just enabled my thinking to get clear and I found I could just step away and go, “Oh, right.” I solely recommend gardening, Lego and jigsaws to [unintelligible 00:39:16].

Dr. Paula Redmond: Brilliant. Julie, what about if we think at a team level because often people talk about how the team is the thing that keeps them going, those relationships are in the team. It can also be the thing that causes a lot of pain if there is division and tension, but what can we do at a team level to support each other or ourselves?

Dr. Julie Highfield: I think key thing that we should do at a team level, is spent any time together actually being a team, instead of arbitrarily calling ourselves a team. Obviously, if there’s a chance for something social, that can be useful, but not everyone wants to engage with that kind of thing, and there’s the pressure of what activity.

I’ve always found over the years, the space to come together and reflect on the nature of what we do is surprisingly powerful. I think models such as Schwartz and all the evidence for that, doing that on a very mini level because actually, getting hundreds of people together is really hard work as per the Schwartz model. I would get five, six people together to talk through something that’s happened at work. Actually, part of that is about processing an emotional outlet for the emotional toxins that are building.

The team-based learning is learning how to be better for each other, hearing each other’s perspectives, realizing they’re not alone. You’re in that connection, you’re reconnecting the team. I think one of the really tricky things is there’s been so much turnover in the NHS, that actually, that sense of team is really unstable, but it surprisingly, doesn’t take a lot just to get to know each other.

I did this thing my own service, where I facilitated a half-day team event where half of it was a game around everyone submitted their answers and then it was a game of guess who. Basically, guess who said this about themselves? We just had a giggle with that. I think the thing that surprised me is I felt great afterwards, actually. It was meant for them, but I felt really good because I had that opportunity to connect and then the other half of it was saying, this is what’s going on. They felt connected to almost their place within the system and know what they’re contributing towards.

It’s that sense of connection and that sense of belonging as well. Those two things and those perspective taking, I think that’s quite important. I guess there’s a part of me that’s a little averse to just plunking in something that feels like, “Oh, here’s just an event for people to go to,” because I think a really key thing around teams is feeling safe to be yourself and that psychological safety. If there hasn’t been almost the structure and framework of work to create that sense, then to say, “Let’s all go on a kayaking course together,” people may not already have that safety at work and it may extrapolate and actually make things worse.

Although I’m not against that kind of team building idea, I think that works well when the teams are already functioning, but just wants to take it to another level. There’s something about the boundaries and the fundamentals within work, which are key. I guess the other side to that, when you say we do that, I think what we can do is come up alongside leaders, supervisors, and help them to be in the position of doing that.

One of the things that we have to be cautious of in psychology and in those positions, especially if we’re integrated or sometimes even worse if we’re helicoptered in, is we can be the nice guy, we can play good cop, and that ends up just making the senior team the bad cop. “You get me, but they’ve sent me to you, they couldn’t be bothered themselves.” That’s something I’ve learned over the years, is actually the better position for a psychologist is what I call a stagehand, rather than the main event. We should be enabling from behind the scenes and helping people think, “What could I say? How could I approach this? How can I puzzle through what’s going on with maybe particular tricky individuals in my team or what’s going on in terms of my team purpose?” I think there’s that as a position as well as being in that facilitating team awareness space.

Dr. Paula Redmond: What about at a more organizational level? [laughs]

Dr. Julie Highfield: My organization, my NHS organization is one of 16,000 people [laughs] because that’s the way health boards are set up in Wales. Most NHS trusts are about 4,000 or 5,000 people. My ICU is 350 people, which is the same size as the village I live in.

Dr. Paula Redmond: Oh wow.

Dr. Julie Highfield: I think it’s really important to make that kind of distinction because I think about, one of my random side things I do is I run the community cinema in my village.

Dr. Paula Redmond: Oh wow.

Dr. Julie Highfield: It’s lovely and it’s so hard to please everyone because it’s film and it’s so hard to please everyone. It’s a really important point of learning for leadership in organizations, if you like, which is I can’t get everyone in my village to agree, why would we think that everyone in my intensive care would agree? There is more of a connected purpose in intensive care, than there is in my village, but actually, it’s the same number of people. I just put that out there in terms of realism of helping at that organizational level.

I guess, however, there are things that do seem to help. I think what helps as an organization is setting that tone and that tone of interest and caring and gratitude towards staff. I think it particularly helps to, rather than take that position of don’t forget wellbeing services are here that you can self refer to, don’t forget to sign up to a course, blah blah blah, blah, blah, it takes much more of a position of we recognize that you’ll thrive at work if you are given those core conditions to thrive at work. We recognize that that’s about how we support your leaders, that’s about how we enable your skill set. That’s about how we designate your physical area. That’s how we enable you to not spend 20 minutes hunting for a parking space before you have to come on shift.

From all of those needs, really interesting presentation, totally separate to psychology, but using psychology in terms of Maslow’s hierarchy of needs. I saw literally a couple of weeks ago, where the guy said, “If someone’s not enabled at those core levels, you can’t go up here. We can’t talk about self-actualization and what we’re all here for, if you can’t park.” You might think of it in a totally different area in that we can’t talk to people who are starving about self-actualization.

Actually, this is something that’s fundamentally tricky at that organizational level in the NHS, that other organizations don’t struggle with because Google doesn’t have these conversations about burnout, does it? Google has conversations about thriving and psychological safety, but actually, the NHS doesn’t get those first couple of levels of Maslow right. Actually, it was infuriating during the pandemic to see out-of-work pilots coming into the NHS and setting that up for us. It’s humiliating almost, because that’s how bad it is. I think that there are things that organizations try to do that are far too nebulous and disconnected from that core purpose and it says so much more if a chief exec dons PPE and walks onto a ward, than it does, if they do a big Q&A. That’s not to say they shouldn’t do their Q&A, but actually, it’s in those, again, coming back down to that social connection.

If they walk around and they say, “Oh hey, gosh, I can see how that doesn’t work and you’ve reported it and reported it. Let me undo that chink in the system, so that we can get your pipe work working because your toilets and sinks are constantly blocked,” for example. That’s an example from recently, for me. I think there’s too much of an acting big and acting at a high level, when we should really come down and get some of those basic conditions to work well. Those are physical conditions and those are tangibly skills with the job.

Another thing to add, sorry. Hot off the press, is about to be published, a big study of demands versus resources in ICU nurses. One of the really interesting things in terms of their measured burnout and PTSD and generalized distress and what they looked at multiple regressional analysis were what were the predictors of those. Demands of work are not predictors of those. It’s the resources, but it isn’t a leaflet as a resource or a cake stand as a resource. Integrated resource of attitudes, approach, availability of leaders, education, all of those things. Those job-based resources, which I think is a really important thing to appeal to if there’s any overwhelmed manager listening to your podcast. We can’t reduce the demands in the NHS, in fact, they’re going to grow and grow and grow and grow, unless we start doing what they do in places like Canada, which is saying this year we don’t do liver transplants, et cetera. They just cut services in order to do other services well.

What we can do, is we can think about the way in which we get the basic resources right, so that people can mitigate those demands because people enjoy working hard, if they’re enabled to do so.

Dr. Paula Redmond: I think there’s something about humanizing the system. I think that linked with what you were talking about, the reciprocity and just really seeing the workforce as people who have basic needs that need to be met, in order for them to do these very complex, demanding things day after day, after day. I think that’s a real pain point for people is when they just feel so dehumanized by the work. I think, as you’re saying, there’s a role for us as psychologist to come back to those basics and keep banging on about it.

Dr. Julie Highfield: Yes, absolutely. There’s something else I want to add in, in terms of the individual. I coined a new phrase with a colleague of mine, Matt Morgan, who lots of people know, he’s very out there on social media. We coined a phrase together, which was burn in. The idea is, it’s a theoretical idea, but we both strongly believe in it, is that actually people disconnect to cope. People who are clinically facing disconnect to cope because they feel emotionally overwhelmed. Actually that’s bad for them.

Instead of stepping back, we were talking about stepping in. That idea, instead of burning out that you burn in. It comes from, Matt wrote a book and I helped him contact various people that he wrote about in the book. He said the thing that was amazing is when he wrote the book, he learned more and more and more about people’s in depth stories and he anticipated that would be bad for him. He anticipated that as an ICU doctor, that would overwhelm him, make it harder for him to do his work. If he humanized his patients and their families too much, then he wouldn’t be able to make these really difficult decisions.

There’s lots of literature to suggest that. It’s something in that intelligent kindness literature, Penelope Campling stuff, that does talk about healthy disconnection from the work. I would agree with that, but you can disconnect unhealthily, disconnect too far. The idea that we talked about is actually, if you can reconnect with patients and patients stories and you can find that humanity. There is a whole project called the humanization of ICU. Actually, it’s a Spanish project, but staff often refer to a patient by their bed area, bed number, rather than their first name, or they refer to a patient by their condition, rather than their first name. They think that that’s protective and actually, it causes more disconnection and burnout through that. It’s just a acute phrase, burn in, reconnect.

[00:54:09] [END OF AUDIO]