Abstract

Objectives To identify burnout constructs from descriptions of staff experiences of health inequalities operating across paediatric specialist hospitals and to categorise the constructs according to Leiter and Maslach’s six Areas of Worklife (AWL) model of burnout.

Design A secondary data analysis of a qualitative study using semi-structured interviews and focus groups.

Setting The interviews and focus groups were conducted within nine children’s hospitals in England.

Participants The dataset included responses from 217 individual staff members occupying various roles: leadership, clinical, professional and support. All staff who volunteered to participate were included in the study.

Results The results of this exploratory analysis showed that psychological burnout constructs were frequently embedded in hospital staff’s descriptions of their experiences of health inequalities in hospitals, and relevant excerpts were found for all six domains of the AWL model. Staff described a work environment where socioeconomic disparities increased workload pressures, but efforts to improve services were frustrated by a perceived lack of control in decision making or professional recognition. There was ambiguity of role-based responsibilities for tackling health inequalities and an imbalance between organisational practices and personal and professional values of social justice.

Conclusions There is a reciprocal relationship between health inequalities and burnout experienced by healthcare professionals operating within specialist children’s hospital settings. The extant knowledge and approaches to health inequalities and occupational burnout should be considered in tandem, integrated into quality improvement and operationalised within paediatric healthcare organisations to improve safety and quality of care.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. All data relevant to the study are included in the article or uploaded as supplementary information. Data from this study are not publicly available as per the terms and conditions of the funding of the study.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

• This study applied the Areas of Worklife model to provide a structured theoretical approach to understand the relationship between health inequalities and burnout.

• The study used a large dataset of qualitative data from interviews and focus groups with 217 participants across nine different children’s hospital sites in England.

• The analysis excludes positive actions taken by the nine organisations to address burnout as health inequalities were the focus of discussions.

• The study did not investigate differences in staff perceptions based on their role in the organisational hierarchy, who will have different job demands.

• The study provides novel insights into the intersection between psychological burnout and experiences of health inequalities in hospital settings.

Introduction

The term ‘burnout’ is used to describe stress-related psychological phenomena seen in ‘other-orientated’ occupations that require interpersonal relations and support for the emotional needs of others, such as healthcare.1 A widely adopted definition of burnout includes three dimensions of emotional exhaustion, cynicism (or depersonalisation) and reduced personal accomplishment (sense of ineffectiveness).2 It is not currently classified as a mental disorder or medical condition, can be of limited duration, and is entirely avoidable.3 Paediatric care involves working with vulnerable groups and managing interpersonal interactions with families that are likely unique stressors for those working in the healthcare of children.4 Currently in the UK, demand for child healthcare exceeds workforce capacity, outstripping any absolute increase in the numbers of consultant or trainee paediatricians, as well as children’s community or hospital nurses. Moreover, vacancy rates vary significantly by geographical region, reflecting an imbalance between demand and human resource capacity in different regions.5 The most important known predictor of burnout is staff shortage,6 and health inequalities within a geographical area are often directly associated with lower healthcare staffing levels. Regions with higher social deprivation face greater difficulties in attracting and retaining skilled staff7 8 despite the offer of financial incentives.9 Similarly, a lack of access to education and professional training, outdated facilities and technologies, and lack of wider support services are related to challenges with recruitment and retention.10 NHS (National Health Service) trusts and hospitals form a hierarchy in terms of prestige, training opportunities and availability of resources and ability to attract charitable funding.11 In addition to the geographical area where family and social networks reside, such factors may influence medical trainees’ ranking preferences and competition for foundation training posts and potentially result in a graduate trainee quality gradient aligned to this hierarchy.12 It remains unclear whether the recent change to preference-based allocation to training programmes will be effective in improving fairness and equity while addressing workforce shortages.13 Trainees may be allocated away from support networks, and this has been raised as a concern for well-being.14 There is no available evidence to assess if disparities in training opportunities will map to areas of deprivation. Evidence does show, however, that the inverse care law persists, whereby the socially disadvantaged, who have greater health needs, paradoxically are more likely to receive poorer quality and quantity of care.15 Research with general practitioners (GPs) also found an association between those working with populations with the highest levels of patient deprivation and GP burnout symptoms.16 This relationship is attributed to the challenges of treating patients with multimorbidity17 and greater psychosocial issues, within a clinical context of limited resources.18 The experience of an increased workload with reduced personal effectiveness while working in more socially deprived regions may result in a revolving door of staff turnover and could therefore further exacerbate inequalities in health outcomes for both staff and patients.

Healthcare organisations globally have recognised that health inequalities need to be tackled strategically in order to improve local access to care and health outcomes. A recent scoping review of grey literature identified different approaches at the organisational, departmental or specific patient group level undertaken to address health inequalities in paediatric settings.19 Subsequent recommendations included recruitment of public health-trained and culturally similar staff to deliver hospital and community-based interventions. Despite the suitability of children’s hospitals to conduct public health interventions, there is a notable lack of published research on strategies for tackling health inequalities with a focus on the local population. If organisations are to develop effectively, targeted and context-specific solutions for the increasingly high burnout rates in healthcare, prevention strategies (including those delivered during medical training) need to account for the wider health inequalities landscape in which staff operate. The pressures of the SARS-CoV-2/COVID-19 pandemic highlighted systemic weaknesses in healthcare settings and inevitably led to a significant increase in burnout.20 Franklin and Gkiouleka’s scoping review of psychosocial risk factors for burnout in health workers during the pandemic identified unclear roles, conflicting demands, lack of control and autonomy in decision making, organisational mismanagement and resulting lack of support and poor work-life balance.21 The review’s recommendations called on organisations to address intersecting health inequalities driving occupational health disparities in staff, as well as to acknowledge the impacts of wider social factors in organisational contexts. Similarly, the King’s fund highlighted the continued discrimination and exclusion experienced by ethnic minority staff members as contributing to NHS workforce challenges.22 Despite the increased visibility of health inequalities during the COVID-19 pandemic, there is limited research directly addressing the link between health inequalities and hospital staff burnout. The current analyses form part of a programme of work that included a qualitative analysis conducted on staff experiences of health inequalities in paediatric hospital settings in England. The study found broad acceptance that the reduction of health inequalities was instrumental to meeting the health needs of the population.23 Whereas, at the point of data collection, only partial implementation of strategies and initiatives was evident at the organisational level. This analysis suggested a context where an imbalance between job demands and resources and role conflict existed, which are known psychological precipitants to staff burnout. It is also important to note that staff often originate from local areas and are thus potentially subject to health inequalities as patients or families as well as in the workplace.

The present work adopts the six Areas of Worklife (AWL) model of burnout24 and applies it to qualitative data on staff experiences of health inequalities in paediatric hospital settings.23 The AWL framework is designed to identify weaknesses in organisational contexts that are predictors of increased burnout. It proposes that burnout can result from an imbalance in an individual’s relationship with their work environment across the six domains of workload, control, reward, community, fairness and values. Employees can experience alignment or a ‘good fit’ with their work environment across the six domains, which is said to result in greater work engagement. Whereas a ‘poor fit’ or an imbalance across these domains are the conditions that can give rise to burnout. The discussions of health inequalities experienced by staff in children’s hospitals provide rich insights into the relationships between individuals and the organisations they work in. The objectives of this work are to identify burnout constructs from descriptions of staff experiences of health inequalities operating across paediatric specialist hospitals and to categorise the constructs according to Leiter and Maslach’s six AWL model of burnout. This will allow for an exploration of how health inequalities are contributing to the hospital staff burnout phenomena and to discuss current approaches to mitigation in healthcare organisations.

Methods

Results

A framework matrix with definitions for the six AWL and exemplar quotes for concepts aligned to the six AWL are presented in table 1. Additional concepts of interest are noted in parentheses. The complete table of quotes used in the results is found in online supplemental file 1.

All six AWL were demonstrated during analysis of the transcripts (table 1). This suggests that experience of health inequalities in patients by staff in hospitals is contributing to burnout phenomena.

Workload was a key factor (table 1, section 1). Staff already struggling to meet demands due to limited time and resources sometimes found health inequalities initiatives an additional burden, while organisational priorities such as waiting list initiatives may have limited opportunities to undertake health inequalities work and wider partnership working.

The second AWL (control, table 1, section 2) was highly visible in the data, with staff discussing experiences of lack of capacity and competing priorities. All staff may have felt a lack of capacity and resources to facilitate change, as well as a lack of confidence in asking about and addressing wider determinants of health for patients. Lack of capacity in external organisations (eg, social work) also restricted attempts to provide support for patients.

Reward (table 1, section 3) was a topic raised in discussions at some hospitals, with some organisations reporting prioritising mental health and well-being support for staff while others did not discuss this. In addition, some staff reported a lack of organisational structures to be able to systemically highlight and reward good work.

Some staff commented on experiences around sense of disjointed community and lack of trust (table 1, section 4). Staff reported a sense of hierarchy and feeling disconnected from senior colleagues, trust board members and policymakers. There was also a perception of hostility and disrespect towards social workers from colleagues.

There was a perception of lack of fairness and equity regarding staff and patients (table 1, section 5). First, for staff, it was felt that those in senior positions from privileged backgrounds had a lack of understanding of issues around inequity. There was also one expressed view of unfairness and nepotism around employment opportunities, which was thought to impact staff retention. There was also a perception of an effort-reward imbalance in the opportunity to apply for funds for initiatives and a lack of fairness in organisational structures. Second, there were strong views that patients also experienced inequity, with anecdotes of faster access to healthcare resources for the most privileged, who are better able to advocate for themselves. This affected patient engagement, with more privileged users being most likely to participate in engagement initiatives.

Finally, the AWL values (table 1, section 6) highlighted concepts around a mismatch between organisational values and those of staff, with perceived conflicting priorities around resource allocation and support for staff. Organisational priorities around costs were felt to impede initiatives to improve care.

Discussion

The investigation of staff experiences of health inequalities in paediatric hospital settings provided an additional opportunity to identify contributory factors to burnout phenomena. The AWL model was used as a framework for classifying the structural and organisational elements that logically dominated discussions of inequalities. Discussions around health inequalities faced by their patients and staff experiences in relation to these revealed examples of the six domains of the burnout framework. This exploratory exercise also indicated further areas of research.

Staff pressures associated with high waitlists were frequently discussed in terms of workload, but such pressures also explained the lack of capacity to enact change to address inequalities despite their contribution to greater workload. In discussions of health inequalities, there were reports of increased duration of direct clinical communication with patients, as well as having to provide additional social support needs. Such activities were not considered part of their clinical responsibility. This sense of job role ambiguity and lower self-efficacy are known to contribute to increased burnout.28 There was also a perceived lack of visible reward or recognition for activities aimed at addressing health inequalities and improvements in patient care. The required partnership working with other sectors to address health inequalities was perceived as disjointed and difficult. There was limited access to the leadership feedback and/or opportunity to contribute to decision making, which is considered synonymous with a sense of organisational community, and participants reported an inability to exercise autonomy or to access resources to enact change. White privilege in senior leadership, including professional roles overseeing patient involvement with diverse communities, as well as lack of fairness in training opportunities, were considered discriminatory and incongruent with social justice values.29 30 Discussion of health inequalities also raised issues of fairness and values around visible spending choices and fiscal responsibility by organisations with access to significant resources. Overall, a willingness to drive improvements in services was evident, as was the belief that organisational support for implementation was inaccessible. This frustration in the ability to enact change to deliver better care results in the emotional exhaustion and alienation known to underpin burnout in healthcare staff.

The inability of staff to navigate systems or access resources through better coordinated internal communication was a clear source of frustration. This is in addition to the psychological and moral injury that can result from challenges in communicating effectively with patients and lack of confidence in safe delivery of care, noted here in the example of taking consent and in sedating a child in the car park (see table 1 values and control sections, respectively). The challenges with language and communication in healthcare settings with high levels of migration among patients are well documented, as well as the associated barriers to access to care and risks of poorer healthcare outcomes.31 Training or promotion pathways for clinical translators or translator roles to assist in clinical and non-clinical communication have been recommended to overcome language barriers,32 but such roles were not mentioned by any participants in the present study. The frustration experienced by staff within interpersonal interactions was compounded by the difficulties felt in working with partners across sectors to address the multiple wider difficulties faced by patients irrespective of language proficiency. In the UK, there are larger scale initiatives that aim to address the sectorial and organisational challenges presented by increasing health inequalities like the Children and Young People’s Health Partnership community-based model of care.33 Similarly, in the US, the Fenwick Institute focuses on embedding health equity principles in early career training and in paediatric clinical practice.34

The discussants in the present study described how structural inequalities led to stress in the workplace, evoking issues of trust in workplace relationships and staff’s experience of moral injury. A recent US National Framework for addressing moral injury and burnout in healthcare workers recognised they were distinct but intersecting phenomena, which also led to a conceptual expansion of the original AWL model. In reference to this framework, the staff perceptions of the impact of health inequalities on well-being described here elucidate potential moderating factors between structural environmental level drivers and outcomes for patients and workers. More specifically, the role ambiguity felt about addressing health inequalities, the reliance on interpretation services and frustrated efforts in cross-sector working represent specific types of relational and operational breakdowns that warrant further research scrutiny.

The question of how organisations were addressing health inequalities also led to discussions of the mental health and well-being support available for staff. A prior qualitative study applied the AWL model with surgeons in Canada and found clinicians reported a sense of personal failure if mental health and resilience interventions proved ineffectual and observed factors in the organisational environment were not addressed.35 The present analysis similarly highlights the structural source of burdens leading to burnout. Interventions to address burnout are more successful when they contain both person and organisation-directed components. These include procedural changes to decrease job demands, increase job control and participation in decision making.36 How the work environment is constructed is argued to be a more powerful influence on burnout than individual characteristics in healthcare settings. There are also clear safety implications if staff feel unable to communicate with leadership and raise issues or concerns in their organisation.37 All NHS organisations have a clear commitment to staff well-being. Many, however, are designed to be delivered at the individual level. In the UK, the King’s fund identified proactive strategies and interventions aimed at the causes of stress, including shared governance (involving staff in all levels of decision making), reducing discrimination, facilitating taking breaks with access to nutritious food and quiet surroundings to avoid stress, being within a mutually respectful team working to streamline clinical workflows, with skilled compassionate leadership driven by values of fairness. The elimination of unnecessary bureaucratic processes and enhanced training and role clarity were needed to improve well-being, as well as supportive, as opposed to directed, approaches driven by regulators, commissioners or the use of benchmarking.38 Leadership across all sites described the development of strategies to address health inequalities within their organisations. However, knowledge of these strategies was not universal across all staff groups. The present analyses provide insights into the lived experiences of staff in addressing health inequalities. It highlights challenges to working relationships with leadership and colleagues, mental well-being and poor operational processes that signpost where the above interventions should be targeted. It highlights challenges to working relationships with leadership and colleagues, mental well-being and poor operational processes that signpost where the above interventions should be targeted. This research approach can also inform on the individual differences that can moderate outcomes.

At the organisational level, Burra et al proposed a structural paradigm shift to acknowledge inequities in health outcomes during decision making related to improvement. This included awareness of inequities in data used in quality and safety improvements as well as challenging quality and safety practitioner attitudes that implementation of larger-scale structural change was not within their purview. Similarly, there are calls on the quality improvement community to prioritise issues of inequalities to ensure disparities in care quality are not further widened.39 40 There are also calls for licensing bodies and national institutions (not individual medical schools) to demonstrate a commitment to not only teach social justice, but also how to actively pursue structural change as a social responsibility of all health professionals.41 42 The evidence presented here is that in many cases, staff across all levels strive for social justice in healthcare, but their efforts are frustrated, unrecognised or actively discouraged due to financial and clinical workload pressures. The payment by results model of reimbursement in acute care settings is associated with inequitable resource distribution and may also perversely disincentivise changes that are designed to work cross-sector to address issues upstream in community settings, by prevention of ill health in the first place.43 The landscape described here appears consistent with a state of organisational inertia, whereby there is rigidity in both resource allocation and in the patterns of working structures that combine to maintain the status quo. This state of inertia has long been considered a significant risk to the NHS.44

Conclusions

A reciprocal relationship exists between levels of health inequalities within a region’s population and staff burnout in the local health organisation. This report on staff experiences of health inequalities in children’s hospitals has served to magnify system bottlenecks, identify areas where organisations can mitigate impacts on staff well-being and improve staff retention. Procedural here is a wealth of health research and evidence addressing health inequalities and burnout independently, whereas a combined approach could be used to address the erosion of organisational and social values that underpin a national health service.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. All data relevant to the study are included in the article or uploaded as supplementary information. Data from this study are not publicly available as per the terms and conditions of the funding of the study.

Ethics statements

Acknowledgments

Thank you to everyone at the hospital trusts who helped us arrange interviews and focus groups, and everyone who kindly gave up their time to contribute to our research. Special thanks to Anne Marie Davies, Children’s Hospital Alliance and Alder Hey Children’s Hospital, Rekel Kerr, Children’s Hospital Alliance and Birmingham Children’s Hospital and Alexandra Norrish, Children’s Hospital Alliance and Sheffield Children’s Hospital. Thanks to Tracy Briggs, Heather Catt, Fiona Egboko, Imelda Mayor, Nicola McCreddin, Pallavi Patel, Julie Pearcy, Dora Pestotnik Stres, Esther Primrose and Andrew Rowland for contributions to the wider project.