Work-related impacts on doctors’ mental health: a qualitative study exploring organisational and systems-level risk factors

Abstract

Background

Protecting doctors’ mental health has typically focused on individuals, rather than addressing organisational and structural-level factors in the work environment.

Objectives

This study uses the socioecological model (SEM) to illuminate and explore how these broader factors inform the mental health of individual doctors.

Design

Semi-structured interviews (20–25 hours) and ethnographic observations (90 hours) involving work shadowing doctors (n=14).

Participants

Doctors representing various career stages, specialty areas, genders and cultural backgrounds.

Setting

Three specialties in a public South Australian hospital. Thematic analysis revealed work-related risk factors for poor mental health.

Results

The SEM framework was used to analyse the work environment’s impact on doctors’ mental health. The analysis identified how the layers interconnect to influence risk factors for individual doctors. Microsystem: lack of control over career advancement, disenfranchisement due to understaffing and concerns about handling complex cases relative to experience. Mesosystem: negative impacts of shift work and fragmented teams, leading doctors to absorb pressure despite exhaustion to maintain professional credibility. Exosystem: high patient loads with time constraints and geographical limitations hindering care delivery, compounded by administrative burdens. Macrosystem: the commercialisation of medicine emphasising corporatisation and bureaucratic processes, which devalues professional autonomy.

Conclusions

This study highlights how doctors experience layers of interconnected factors that compromise their mental health but over which they have very little control. Interventions must therefore address these issues at organisational and systemic levels, for which starting points evident within our data are identified.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Data quality: researchers adopted a stance of empathic neutrality, aiming to hold a ‘neutral position’ about information elicited during research activities to gain vicarious qualitative understanding of the research issue.

• Sample diversity: research participants varied in specialty area, gender, cultural background and work experiences.

• Bias to participation: research participants ‘self-selected’ to participate, and accordingly some experiences that impact mental health (eg, intersections of gender and racial discrimination) could be missed.

Introduction

Worldwide, protecting doctors’ mental health is critical. Medical doctors of all professional groups are one of the groups at highest risk of poor mental health, particularly junior and women doctors¹ and medical students.² At all career stages, Australian doctors in particular, have higher rates of depression and anxiety and symptoms of poor mental health than other professionals, notwithstanding the pressures ensued in COVID-19.^{3 4} Fatigue and burnout are known to disrupt good mental health, and Australian doctors report high levels of both.⁵ While addressing the barriers doctors experience to accessing mental healthcare is an important ongoing consideration, this issue is partly due to doctors’ perceptions about stigma, interlinked with concerns about confidentiality and compromising registrations if they seek help. Accordingly, there are concerns about the suitability of individualised approaches to protecting doctors’ mental health in the absence of support within and outside of the organisation in the form of structural-level change. This includes considerations about the suitability of approaches delivered through employee assistance programmes designed to improve doctors’ resilience through coping strategies (e.g., undertaking training in mindfulness or mental health first aid), which not only risk alienating doctors because they come to feel personally responsible for their work-based distress, but indicate how such approaches might be misdirected.

A 2018 review of contributors to depression and suicide among Australian doctors³ made a strong case for focusing on work-related factors, including working conditions and workplace professional cultures, and for building interventions that take into consideration the impact of bullying and discrimination within professional colleges on doctors’ mental health.⁶ It emphasised systemic culture change as critical to ameliorate stigma associated with help seeking.⁶ A review of literature on the precursors to doctors’ poor mental health published the following year in The Lancet identified an urgency for organisation-level interventions targeting structural (rather than individual) risk factors.⁷ Mental health risk factors posed by doctors’ work environments, including organisational relationships, work-related systems and characteristics of the workplace, pose major threats to mental health. Yet, these modifiable risk factors in the work environment that might reduce burnout and create conditions to protect doctors’ mental health remain unaddressed. This is particularly concerning given the COVID-19 pandemic placed additional strain on health systems globally, and in Australia worsened working conditions for doctors⁷. More broadly it is well documented as accentuating pre-existing concerns about doctors’ mental health.^{8 9} The pandemic further emphasises the continued need to focus on improving work-related conditions¹⁰ for doctors and to direct resources at changing workplaces to support mental health.

This research paper extends from a rapidly expanding literature on doctors’ mental health before and during the COVID-19 pandemic, and specifically explores the impact of work-related risk factors from doctors’ own perspectives, that if modified, would enable doctors to use existing help. It might even reduce the need for support by creating conditions that promote and protect doctors’ mental health. The research question was: what are the work-related factors operating at the organisational and structural levels that doctors perceive impact on individual wellbeing? A qualitative approach to data collection was used to explore Australian doctors’ emic viewpoints and experiences of factors that contribute to burnout, fatigue and anxiety, not previously reported in literature that calls for systems-level responses. Interviewing individual doctors and then work shadowing them while they were on shift enabled unique in situ observations of the workplace contexts and conditions doctors describe, reported here in detail. Doctors’ own insights explored through a socioecological model (SEM) allow the identification of new evidence-based strategies to create systems-level change, which if achieved could potentially protect doctors’ mental health.

Conceptual model: the SEM applied to workplace impacts on doctors’ mental health

Bronfenbrenner’s^{11 12} SEM detailed four ‘layers’ of environmental influences on individual outcomes he described as: microsystem, mesosystem, exosystem and macrosystem. When the SEM is applied to doctors’ descriptions of their feelings about their work, the factors that impact their wellbeing within their workplace environments become visible. Drawing on hospital data, unique insights into how the organisational and structural characteristics (including the systems, processes, policies, teams and interpersonal relationships) which intersect with workplace realities, professional cultures, and doctors’ working lives in ways that are potentially fractious for mental health, become clear. By illuminating the interconnections between layers of structural factors and individual mental health, this paper responds to urgent calls for increased employer responsibility for the establishment of ‘mentally healthy workplaces’ to reduce burnout in doctors.⁶ The microsystem depicts individual doctors’ beliefs, behaviours, knowledge, self-concept, attitudes and physiology, culminating in their state of psychosocial health. This includes doctors’ roles, the activities they perform, physical features of their work environments, the time and place of service delivery and interpersonal relationships (with colleagues, supervisors, patients, patient advocates/family) within the work environment. The mesosystem is the interface between the individual and their community and groups within the community. For the doctors in this study, this included the hospital and related health services doctors’ practice within and their social support programmes, including programmes offered by their workplace, and informal supports outside of the workplace (e.g., support from family who are medical professionals). The exosystem concerns organisational qualities or health service-level factors including regulations, standards and training requirements. The most external layer is the macrosystem, including the values and ideologies that give meaning to the role of doctors within society, and institutional and belief systems that shape an individual doctor’s philosophy and ethos about their role and professional practice. In the context of doctors’ mental health, this conceptual approach identifies the interconnections between biological expressions of mental health including unique personalities, temperaments and dispositions (i.e., resilience or ability to cope) and work-related factors or workplace conditions that affect how they feel and think about their work. The complexity of factors attributed to doctors’ mental health requires observational insights as well as listening to doctors themselves.

Methods

Data collection used semi-structured qualitative interviews and observations of 14 doctors through work shadowing them while on shift. Both methods were conducted by author KF who is a registered occupational therapist. Contact and recruitment of doctors was guided by a multidisciplinary team with different levels of seniority, some of whom worked within hospital management to develop strategies that would support doctors (particularly junior doctors) to participate. This was critical because the study design involved work shadowing, which made doctors who volunteered for the study ‘identifiable’ to their colleagues. We purposively sampled from different specialty areas across a public hospital and related health services, based on evidence about workplaces most risky to mental health, at different shift times, until no new data emerged and saturation was reached. The study design and sampling strategy were also informed by contemporary literature about specific risks to mental health for doctors (i.e., gender, career stage, discipline) and sought to include variety within these variables. The sample comprised doctors of different genders, ages and career stage, cultural backgrounds, international work experiences and different family responsibilities.

Information about the study was circulated to doctors via email distribution lists. Senior doctors who volunteered were scheduled to take part earlier than junior doctors working in their departments, to signal trust in the research team and the value given to the study by hospital management. The aim was to offset doctors feeling that their participation in the study would be interpreted as an act of protest against their workplace or sign of weakness regarding wishing to prioritise mental health promotion. Doctors interested in volunteering sent an email to author KF who scheduled an initial meeting to talk through the risks, opportunities and potential complexities of the study before providing their informed consent to take part and completing the interview component.

After the interview, another opportunity was provided to discuss how the work shadowing would proceed and organise suitable times for data collection. At this point, doctors were reminded they could withdraw from the study at any time with no negative consequences. Given the small number of doctors in each specialty/career stage intersection, it was reiterated that the insights they shared and events on shift, which may be re-identifiable, would be removed before data would be included in reports, academic manuscripts and other publications, to minimise the chance for their contributions to the study to be recognised by others. Doctors were invited to review data arising from their participation prior to publication, although only some took this opportunity.

Qualitative semi-structured interviews

Qualitative semi-structured interviews were undertaken with 14 doctors of different genders (6 men and 8 women), career levels (5 consultants, 3 resident medical officers (RMO) and 6 registrars) and specialty areas (n=3 different areas), lasting a minimum of 60 minutes (25 hours total). Interviews were undertaken face-to-face on shift for all except one RMO and one consultant who preferred to be interviewed by telephone from home, with times advised by participants - typically in the afternoon on rostered administrative days for consultants and over lunch break for RMOs/registrars in specialty departments, but also at short notice per each doctor’s availability depending on patient flow. Some interviews were disrupted or changed locations mid-way because of minimal physical space available within the hospital.

Interviews explored how workplace factors, including professional and workplace culture and organisational and health service contexts, influence doctors’ experiences and perceptions of their work. Interviews privileged doctors’ subjective experiences of time spent in different workplace settings and experiences of practising in their profession.¹³ Doctors were asked what they felt could change to create working conditions that support mental health, resulting in suggestions for workplace-level interventions that doctors co-produced through the research process (see online supplemental file 1). Interviews were audio recorded and anonymised before they were transcribed verbatim.

Work shadowing

Doctors who participated in an interview were asked if the interviewer could ‘work shadow’¹⁴ them while working on shift (at times they selected). This allowed the workplaces doctors described in interviews to be observed and options for intervention identified first-hand. Variability was achieved in the timing of the shift (including both early mornings and late evenings) across each specialty area; and observational prompts included team structure and composition, environmental factors like noise, physical clutter and the nature/complexity/number of co-occurring tasks (including supervision of others), if and when breaks were taken, as well as other factors doctors described as being prescient to their mental health during the work shadowing period.

This form of organisational ethnography was conducted to understand the breadth of factors that might impact doctors’ mental health; particularly as some might be highly routinised and banal for doctors and therefore not notable during the qualitative interview.¹⁵ Author KF work shadowed doctors for one to two sessions each (approximately 8 hours per doctor; 90 hours of observational data total) from June to October 2021 to observe the processes doctors undertake to adapt to and within their work environments. Fieldnotes were written during work shadowing following a template (see online supplemental file 2), including doctors’ use of metaphors to describe their work and workplace conditions (e.g., ‘hot’ to depict pressure and a sense of continual urgency), and the typicality of their experiences and interpersonal relations in the work environment.

Recruitment and ethics

Doctors attended an information session and were provided with information sheets by which they could volunteer. Project recruitment materials were emailed to departments by administrative staff, and doctors were advised there was no obligation to participate. The recruitment process recognised that the topic is sensitive and doctors might be noticed as participating during work shadowing. Accordingly, consultant doctors participated first, to role-model to junior staff that participation in the study was supported by their department. Doctors were advised at the beginning of interviews that the researcher (Author KF) was a mandated notifier and they could select what they disclosed during the interview. Participants were provided a range of wellbeing policies and supports offered through the hospital as well as counselling and support services external to the hospital, and advised that a senior psychiatric doctor (Author M Baigent) would be willing to meet with them if they had any concerns about the researcher or their mental health. The data reported here comprise excerpts from interview transcripts and researcher’s fieldnotes made during work shadowing. Participant numbers are used instead of names to preserve confidentiality, and some details have been changed to reduce the extent to which data may be reidentifiable.

Patient and public involvement

None.

Data analysis

Coding occurred in three stages: precoding, conceptual categorisation and theoretical categorisation.¹⁶ Precoding was inductive and deductive to investigate the various themes that emerged. First, author BL inductively precoded a selection of transcripts (high/low-risk workplaces, junior/senior doctors, male/woman/other) and identified common words and phrases¹⁷ that became codes. Inductive codes were then organised into categories under themes according to Bronfenbrenner’s SEM layers per contemporary approaches to framework analysis.^{18 19} Coding was then undertaken progressively as interviews were conducted and fieldnotes generated using the SEM to identify leverage points for systems-level change. Analysis resulted in an ‘implications for practice’ code per theme (e.g., ‘leadership’ had a corresponding code ‘improve corporate memory’ with the same excerpt coded at both) to ensure the evidence underpinning the suggestion for improvement was identifiable.

To enhance rigour, authors BL, PRW and KF each deductively co-coded several transcripts before discussing findings, ensuring interpretive reliability.²⁰ All transcripts and fieldnotes were deductively coded by BL against the coding framework using QSR NVivo software (V.13) by extracting whole phrases relevant to the concepts comprising the framework (termed ‘deductive inference’).²¹ Attention was given to findings that fell outside the SEM, and these abductively derived codes were identified as areas for research extension in additional studies.

Results

Analysis situated risks to doctors’ mental health in the context of work-related impacts, structures and processes and resulted in 72 major themes. The most prominent themes (depicted in figure 1) are reported, and those that are immediately actionable through organisational changes with potential to improve doctors’ mental health.

Figure 1. Risks to doctors’ mental health in the context of work-related impacts, structures and processes.

Microsystem: doctors’ immediate physical, social and work environment

Confidence, career trajectory, professional experience and exposure levels (relative to career stage)

The inability to manage emotions around risk while working in a high-paced environment was a skill demand that senior doctors described could lead to stress, especially for junior doctors. They described junior doctors’ tendency to ‘shy away’ from risk in medical practice as a way of constricting their ‘risk threshold’. Senior doctors also described limitations in junior doctors’ willingness to accept risk; describing doctors who are unable to ‘run the risk’, ‘cope with more’ or ‘be comfortable with risk’, even though risk is inherent to medical practice. Risk is a feature of contemporary hospital settings, particularly hospitals in crisis during the pandemic. They conveyed that junior doctors are disenfranchised and disempowered by the power structures of their work environments and of their profession. Likewise, junior doctors expressed feeling that the ‘structures’ do not care about them and that when permitted to ‘jump into a role with no supervision’ (Participant 6), their comfort with decision-making was negatively impacted, in turn negatively impacting their mental health. Despite potentially feeling their level of exposure to decision-making was inappropriate relative to their career stage and experience level, junior doctors recognised that if they turned down an opportunity for promotion it could be interpreted negatively by administrative and senior staff, to the extent that they might then be overlooked for career progression opportunities in future because they lacked confidence.

Control, autonomy and expectations on doctors’ time

Doctors across the study reflected the feeling that: ‘everything is an emergency!’ (Participant 8), and described conditions where working ‘was busy and stressful’ (Participant 5). They explained that they are ‘interrupted all of the time’ (Participant 7), and the concentration required to maintain focus was draining. This backdrop shaped their capacity and experiences of performing good clinical care:

The nurses will talk to me, so that’s when we’re talking about the cognitive load. Like that’s when task switching, it starts to grind. There’s so many [interruptions] and so my anxiety…I start to get more snappy, like ‘stop talking!’ (Participant 2)

Doctors felt that complexities of care delivery were made more complex because of the competing expectations and pressures on time in accordance with vast patient loads. One doctor remarked: ‘the hospital processes are more stressful than clinical scenarios’ (Participant 1). This resulted in ‘regular’ care delivery feeling more stressful than it perhaps would otherwise have felt or ‘should’ have felt. The observed need to complete copious administrative tasks attributed to short staffing, while also avoiding frustrating other (typically more senior) doctors or administrators for fear it could develop a bad reputation and compromise career trajectory, caused significant stress:

I was bawling my eyes out not knowing how to word the email thinking that they were going to give me a bad review […] or tell the consultant […] because the consultants get told the juniors are complaining about the roster or they feed back to my supervisors… and then the following year, I don’t get the rotations that I want. There’s this constant threat of… because what I said at the beginning… that power that they hold, which they think is innocuous, they’re like, ‘oh, it’s just a rotation’. It’s everything to us because otherwise you miss out on meeting those mentors. There’s so many things that have to fall into place and they don’t seem to care. They just seem to want to fill the gap in their spreadsheet and they don’t think of the person that’s doing it. (Participant 13)

The sense of impending and continuous danger of damage (a ‘threat’) negatively impacted doctors’ confidence and assuredness about their work. This was especially true for more senior doctors in the study, who tended to absorb more responsibility for others’ actions including through clinical practice but also administrative labour expended in advocating for junior doctors. Junior staff, on the other hand, expressed strain in managing the unpredictability of their shift length and requirements. This was particularly acute if they were part of a smaller specialty area, because any outstanding tasks critical for patient care could not be handed over given there were no incoming staff until the next morning. Day shifts tended to run 07:00–17:00, while some staff were additionally on call overnight and throughout the weekend (i.e., Friday 17:00 until Monday 07:00). On a ‘bad’ weekend, this could mean staff were working overnight during weekends and with minimal time off before their working week started again at 07:00 on Monday.

Mesosystem: workplace teams and community interface

Team membership

Doctors described synergistic teams that they felt were conducive to healthy work environments and to feeling supported within their profession but identified how within the context of Australia’s public health system during COVID-19 teams seemed to be disparate and fragmented. Doctors offered structural factors as reasons for this divisive effect. In particular, disruption to teams occurred through rotations and perhaps was symptomatic of mostly online interactions between doctors across sites through tele-software per COVID-19 distancing measures (observed through work shadowing). This meant physical interactions did not often occur between doctors across locations within the hospital. One doctor described barriers to help seeking because of temporal shifts in the constitution of teams, and their fears about reputational damage if they spoke about their mental health with unfamiliar colleagues:

It’s great to have a good team dynamic but you’re constantly inserting yourself into that team dynamic. I’m also new and learning about this and I stuffed up. Can I talk to one of you about it? [unlikely] It’s not ideal, it’s an extra challenge. (Participant 9)

There were also subtle ways that team configurations and the expectation of being ‘team-minded’ within doctors’ professional culture had pitfalls for mental health. Doctors described not wanting to ‘let the team down’; but this meant working overtime while exhausted coupled with a reluctance to take leave (for self-care purposes such as needing a break or having a psychology or general practitioner appointment), because backfill would need to be provided by colleagues also under strain. By not showing ‘team-mindedness’, doctors described feeling there was a risk their capacity or value within a team would be questioned, through feedback colleagues provided about them, by administrators from whom they must seek leave approvals, and may impact the opportunities they were offered in the future. This was expressed by some junior doctors as extreme hesitance to ‘bother’ senior staff (reserving interruptions for core business needs such as advising on how to administer clinical care), and only call them as a ‘last resort’. This was observable even in teams where senior staff described actively promoting a supportive workplace culture, and perhaps speaks to the density of expectations in medical working spheres.

Expectations of profession and coping

Doctors’ mental health was negatively impacted by the expectations and ‘work ethic’ of the medical profession that included absorbing the conditions of the work however tenuous (and various extremely high-pressured environments were observed), in which doctors were anticipated to cope well (or ‘get on with the job’). Elements within the organisational system and pressures resulting from the way doctors’ work is designed and coordinated were observed to adversely impact mental health. This is potentially due to the aforementioned workforce demand resulting from a shortage of doctors, exacerbated by exposure to COVID-19 cases and/or illness among doctors. Doctors described how responding to consistent administrative pressures generated at the systems-level in turn created fragility in their feelings of competency. For example, junior doctors explained they felt a ‘push to progress’; that they ‘should’ want to seek advancement, to ameliorate workforce shortages and show they were committed to the profession.

While being work shadowed through administrative duties alongside clinical work, one junior doctor (Participant 13) said they feared that if they took a break, they ‘don’t get the rotations I want’ or that they might ‘miss out on meeting those mentors’, who they felt would improve their chances of career progress. Doctors also felt the organisational processes involved in scheduling shifts are distant from their real-world experiences. This was reinforced by fluctuating workloads and the uncertain patterning of shifts/loads, observable as work-shadowed doctors were called on to do hours of overtime without warning. One doctor remarked while being work shadowed that their increased immense workload felt ‘endless’ because there was always work left to do despite reaching the end of the shift (particularly in the evenings):

When I was a resident, you could sort of hope to get on top of my workload by the end of the evening, if you’re on night [shift]. It certainly wouldn’t be as onerous. (Participant 12)

Social support within the work context

While being part of a high-functioning, stable team bolstered mental health, doctors’ narratives were littered with examples of microaggressions such as towards the gender minorities of the profession.²² Men doctors realised their gendered privilege and explained feeling a sense of increased aptitude for their profession accordingly. This aptitude they felt was reflected by high levels of patient trust:

I’m an older male who has grown up within this cultural context […] but no one’s ever specifically said, obviously, that they trust me more, because I’m a male or whatever. But there’s kind of like this subtle interplay over time where there’s an implicit trust that happens because of that position, and then you gain more confidence, and then that reinforces… it becomes a very positive reinforcement loop. (Participant 2)

Women doctors also discussed overt disadvantages of their gender for certainty and confidence in career progression. Their experiences reflect the subtle but insidious nature of gendered disadvantage within the medical profession, including how family planning intersects with competitiveness for future rotations. This had implications for burnout, whereby women doctors conveyed how they attempted to manage their family responsibilities in ways that did not interrupt their working lives nor their career trajectory, despite their personal lives requiring large volumes of time (e.g., caring for a family member or having children). For example, recognising that an academic research track record bolsters chances for appointments, while being work shadowed, one woman doctor reported that she undertook doctoral research within maternity leave because she feared that taking time off would seem uncommitted to her career and also be punished within the training structures, by way of needing to repeat elements to demonstrate currency:

… if you take more than 6 weeks of leave then that 6 months of your work training is disqualified - it is deemed that too much work has been missed and this part of the training pathway will need to be repeated. (Fieldnotes from work shadowing Participant 6)

Another senior woman doctor described the strain she experienced with co-existing gendered expectations placed on her as a professional but also a mother, wife and carer, and this compounded experiences of stress in her workplace and work-related roles:

I was coping with those two [major life altering] things, as well as all my usual stresses. So, a lot of pressure to absorb. And then [someone close to the participant] was diagnosed with this terrible [illness], and [someone close to the participant’s daughter is experiencing crisis]. So, you know, a lot of uneasiness… But I think I’ve always had fairly robust mental health. I talk to [a family member] once a week, who is medically trained, and I think that’s quite helpful. (Participant 3)

She described feeling fortunate to have access to social supports from a family member experienced in the unique pressures faced by women doctors, and said she knew that speaking with them would not risk her professional reputation. However, this mesosystem layer of support is not a systemic feature of work-related environments for all doctors.

Exosystem: organisational and health service factors such as regulations, standards and training requirements

Workload pattern, balance and flow

Constraints on doctors’ practice according to structural factors like demands on time relative to workflow and resources including geospatial issues that affect treatment conditions (e.g., a lack of privacy for patient consults and disruptions in the continuation of patient care between different sites within the health service) were all observed during work shadowing and appeared to cause doctors angst. Doctors described discrepancies between what they thought was ‘ideal’ practice and what was feasible within the organisational system, which led to stress and cognitive dissonance, but were nonetheless absorbed as being their ‘fault’:

I probably empathise too much with the patient because I always feel terrible if they’ve not been delivered a good service, if the outcome is poor because they’ve had a terrible accident or got a terrible illness, I can rationalise that. But if they’ve had a poor outcome because we’ve not been able to deliver them a good service that feels a lot worse. (Participant 3)

The practices that govern the medical profession felt to doctors ‘impossible’ to change, especially unrealistic work hours. Doctors described a corporatised health system where junior doctors in particular felt fear around facing reprimands through ‘tight’ governance. The workloads doctors’ reported within resource-poor conditions were anachronistic relative to time available and absorbed as unideal aspects of their work but also expected as ‘part of the job’, contributing to cognitive dissonance. The following excerpt indicates how this can lead to feeling burnt out:

I think that just bubbles over years. And it just makes this horrible feeling of injustice. Which is why I think doctors just feel burnt out, tired, frustrated, because they’re trying to do the right thing, and they’re trying to be better and the system just doesn’t allow it. (Participant 13)

Several doctors accepted responsibility for stressful work conditions by adjusting their own practices, and it appeared that doctors felt pushed, and pushed themselves, to the edge of their capacity in order to cope:

We just keep taking it, keep taking it, keep taking it, keep taking it …until we can’t. And I think, particularly doctors who don’t want to be seen as causing trouble or rocking the boat… or seen as weak. You don’t want to be the one to admit that actually, this is impossible for one person to do. (Participant 13)

Emotional labour and compliance

Doctors felt a duty to comply with work-related conditions that adversely impacted their mental health, contributing to burnout and anxiety. They described a decision to join the medical profession and therefore ‘knowingly sign up’ for a profession that involved long work hours and challenging conditions. Accordingly, they seemed to think they must accept the workplace cultures and conditions that have come to characterise the profession (however stressful). While being work-shadowed, doctors used phrases like ‘you’ve got to earn your stripes’ (Participant 2), as they encountered complicated and unideal work-related situations, which expanded beyond clinical complexity.

Data provided a sense that doctors expended energy to manage emotions and resist admitting they were not coping. Doctors felt being seen to not be ‘keeping up with appearances’ would be disparaging to their professional reputation. They expressed anxiety and (hyper) vigilance to not be viewed as such. Perhaps, this explains doctors’ aversion to help-seeking before burnout occurs. Doctors at all career stages said they envisaged no other form of work (i.e., some described that the profession ‘is’ their identity) and thus embraced difficult conditions as simply ‘the nature of the work’ (Participant 6), the ‘nature of medicine’ (Participant 12) or ‘the nature of clinical practice’ (Participant 1).

Amidst the emotional labour and potential vicarious traumas that were observed to arise during clinical practice, doctors described explicitly working to manage the emotional strain felt about their work, to remain ‘level’ and enable continuation in their working lives:

I think initially that is the challenge for any young doctor, to being able to not take things too hard when you’re confronted […] and hearing those stories… sometimes can have an emotional impact……I think there’s a cumulative effect, eventually where it’s important to still be able to empathise with patients and to feel something. But you also have to sort of keep that in check; in balance. So I think that is an interesting navigation that you have to do, you don’t want to just be robotic in how you do your work. But you’ve got to protect yourself by not letting things get to you, and I think that’s one aspect that makes it quite challenging. (Participant 1)

Observations made during work shadowing uncovered a ‘resigned acceptance’ where doctors perceived that nothing could change. This seemed to deter doctors from making a disruption because it could risk drawing negative attention. It could also risk professional opportunities because disruptions are counterproductive to scheduling and trust in the ability to complete work. As one doctor explained:

There are circumstances where you do definitely look for the keys of what your consultants are okay with because you don't want to be seen to be making noise. (Participant 2)

Doctors in the study were hesitant to upset the status quo because they described non-compliance being viewed as disruptive to the functioning of the health service.

Macrosystem: institutional factors and philosophy/belief systems

Corporatisation of health care

Doctors described feeling that the corporatisation of health has resulted in a ‘complete disconnect between the public administrators and the doctors’ (Participant 11). They outlined bureaucratic processes that caused them to question their agency and think their input was not worthwhile when weighed up against the taxing nature of using energy that could be spent on patient care. One doctor explained not: ‘having the time and energy to bash your head against that brick wall’ (Participant 3). Doctors were observed using cynicism and sarcasm during work-related interactions, seemingly to cope. For example, phrases like: ‘we don’t have a calm pace’, and when work shadowing, a colleague was observed asking if they could ask a ‘favour’ of another doctor (to see a patient - a core work task), but before they could ask, the doctor responded, ‘I do want to jump off of a cliff, yes’ (Participant 6), interpretable as a way of collectively communicating about and navigating the extreme mental load that accompanied their work conditions.

While work shadowing doctors, a sense of the political structures enfolding health management leading to ‘sentiment without actions’ (to use the words of one doctor) was observed. This appeared to damage feelings about professional worth. One doctor commented: ‘health now runs like a business’ (Participant 1), and described a loss of a ‘sense of unity as an organisation’ (Participant 1), and with this loss, said that the feeling of having a support network within the workplace also diminished. These divergences in doctors’ philosophical ideals about the medical profession including what they gain from doing their job, what they want to give to their profession and the way society perceives medical professionals, which in turn shapes patient expectations and experiences, meant that being unable to meet these expectations was felt as deeply injuring:

You’re striving and becoming this professional…this pillar in the community. In addition to all that knowledge and actual competence that you need to have, it is so important to convey to others that you are this rational, measured human being who is there to get the job done in an efficient way, in the right way. You just have to step up to that role and fulfil all these different tasks, and different expectations within this one job, because you end up doing so many different things and taking so many roles and many other different jobs as the doctor […] at the end of the day, you're this one [doctor] with this responsibility, and everyone looks to you to deal with it or to take responsibility for what’s going to happen to a patient. (Participant 4)

Bureaucratic processes

Doctors seemed to feel dispensable within the organisation (as depicted by this participant’s earlier comments about the rostering spreadsheet) and the contributions they made in turn seemed minimised. Bureaucratic processes sent messages to doctors of their relative insignificance as a working ‘cog’ within a bigger ‘machine’, that if ‘broken’ is replaceable because as one doctor said during work shadowing: ‘the hospital owns you.’ (Participant 14) A lack of autonomy seemed to create a sense of meaninglessness or loss of value in their work. One doctor explained how she wanted to reduce hours in order to reclaim some personal time but concomitantly felt despondent because it would make things ‘harder for herself’—again with an emphasis on this being the career she had ‘chosen’:

My colleague and I are full-time but want to be part-time, and have applied to be part-time and then have been told that it might not be possible…the fact that we want to do part-time… we should be able to. The more people that can get together, the stronger that will come across? […] To be honest, things probably aren’t gonna change. There is a bit of like, okay, I guess we’ll just keep going. And this is how it’s been […] it’s not going to change, this is the career I’ve chosen. (Participant 12)

Occupational prestige and ‘bravado culture’

Doctors felt the system permitted burnout by relying on them to cover up organisational shortcomings:

‘instead of someone doing a model and predicting it they just wait to see if we can cope and because there’s a bravado culture we just keep taking it’ (Participant 13).

The reference to ‘bravado culture’ here reflects the occupational prestige of the medical profession where within broader communities and reflected by patients, doctors are ‘heroic’ and held up on pedestals. Consequently, their emotional management seemed focused on pragmatism and maintaining a sense of the relativity about their discomforts by comparing with their patient’s discomforts. Doctors’ dutifulness in providing continuous care above their own needs as a coping strategy, and perhaps because it is expected of their socially constructed role (and ensuing pressure) as ‘saviour’, is captured here:

The nature of medicine is that the patients don’t get to go home, you know they’re still there. They still need care. And they’re going to be there tomorrow. You obviously take that with you. (Participant 9)

This response requires that doctors show resilience and potentially ‘mask’ the impacts of their working conditions, and is a key point where these data allow critique of individualised approaches to mental health. It encourages what one doctor called a ‘logical dispassion’ (Participant 11), which they demonstrated while being work shadowed. This is concerning as it risks doctors becoming estranged from their feelings entirely, disguising or perhaps characterising burnout:

I think it’s the nature of dealing with mental health, emotional problems, psychological sort of problems. As a doctor yourself, you have your own mental health issues and emotional issues, you know, that we all have in our own personal life. So in clinical work there’s certain sorts of situations that for want of a better word, sort of resemble things that you might experience in your own personal lives and challenges that you’re facing, but being able to lock that away, and to come in, and to deal with every sort of significant emotional trauma and other types of psychological issues that you see in your clinical practice can be very taxing. (Participant 1)

A compartmentalising strategy to protect mental health seemed most feasible for doctors who worked in specialty areas where they experienced team connection, high morale and opportunities for mentorship (protective of wellbeing). Doctors who do not have access to these protective factors seem particularly at risk of poor mental health. Altogether, it emphasises the impact of structural factors on individual doctors’ wellbeing, which can be moderated by some intermediary factors, but which do not reflect systems-level solutions that promote and sustain working conditions that are protective of doctors’ mental health.

Discussion

Leverage points for systems-level change to improve doctors’ mental health

Using the SEM to organise and interpret results, this study makes clear where and how interwoven organisational and systemic factors contribute to burnout and stress among individual and collectives of doctors. This SEM approach demonstrates the complexity of layered impacts on mental health that doctors in our study experienced. Notably, the SEM has been critiqued for simplifying complexity needed for systems-level change and health promotion.²³ The virtue of applying this model to explore the work-related impacts on doctors’ mental health specifically is that it allows the direct identification of factors amenable to systems-level change through targeted and multilevel interventions. For this study, the importance of systems-level changes is also conveyed through the SEM. Dominant conceptualisations about doctors’ personal responsibility for mental health can be challenged accordingly; while organisational cultures and interpersonal workplace relationships conducive to mental wellness can be fostered.

As a starting point, doctors at all career stages and within diverse specialty areas would benefit from formalised resolute displays of support from within and across their profession, including the colleges, but also by management within the organisation (at the broader institutional level). According to doctors themselves, this could begin with leadership that is ‘visible’ to doctors through advocacy for enabling organisational change (one doctor said it ‘provides some morale to the troops’). The onus on individual senior doctors to mentor and guide juniors (which data reported here show currently occurs despite the stress it entails) might be too arduous in the context of workloads and time constraints (depending on the specialty area).

It is critical that senior doctors feel recognised by the organisation as having limited agency to manage workplace factors that shape their mental health (and that of the junior doctors they mentor and seek to shield), while working within a corporatised and under-resourced system. This might include recognition of the limitations of doctors’ time and energy levels, offering a systems-level mitigation to burnout. An obvious inlet to change would be to ensure doctors can take sick leave if needed or plan holiday breaks into a year, rather than being paid out for their leave at the end of contract years because they are unable to take it due to staff shortages (before starting another contract immediately, with no gap). This seems to link with needed changes in the culture and expectations of the profession - of the emotional strain doctors experience in being positioned at the intersection of these layers of pressure, and in feeling expected to hold everything together in the absence of supports or release. Allowing doctors to take breaks (even during shifts) would materially and symbolically denote the value and complexity of their work.

Regulations and standards of training also warrant attention in order to moderate the (perceived) competitiveness of appointments. The results reported herein suggest this would potentially increase doctors’ self-determination about timing for career advancement and help achieve work-life balance allowing for improved mental health. It also extends to dispersing workloads fairly, while being mindful of the pressures on clinical decision-making among junior doctors, who feel the system ‘rushes’ them into practice situations outside their experience level to ameliorate workforce shortages. This, in turn, fosters discomfort among juniors toward ‘risk’ (although innate to the medical profession) because the precarious and under-resourced working environment adds challenges to their clinical practice. This would not be present if the system were functioning appropriately.

This study shows that workforce shortages must urgently be addressed to enable doctors to experience work conditions they feel support optimal clinical performance, rather than detract from it. Administration could evaluate and monitor leave taken and engage with doctors’ concerns that if they take time off, they will lose competitiveness for the next rotation. Colleges could review the way training programmes are structured including how they enable leave breaks for caring roles. Suitable and feasible leave entitlements would signal to doctors that the workplace pressures they experience are acknowledged and that the onus on personal resilience (whatever the working conditions) will potentially ease. Bureaucratic ‘red tape’ that creates overly cautious doctors and compromises self-assuredness must be recognised as compromising mental health and must be addressed. A beginning point could be basic structural changes such as improving physical spaces to appropriately care for patients, which would be an important signal to demoralised doctors that organisational factors, particularly those suffered during the pandemic crisis (and some that continue), will be improved. The critical importance of addressing moral injury, described as the ‘impossibility or infeasibility of enacting quality care in the face of institutional constraints’²⁴ (p 2) links to psychological distress and burnout.²⁵ An inability to uphold high standards of practice due to systemic factors leads to the internalisation of guilt, as data presented here show. This is concerning given studies suggest moral injury is interpreted as a personal failure despite the root cause being circumstances beyond individual control.²⁶

Areas for research extension

The purpose of this paper has been exploratory given the paucity of literature applying a systemic approach (ie, SEM) to doctors’ mental health within hospital organisations and professional cultures - a hardly reached population. The SEM allowed a framework broad enough to allow researchers to remain open to the results of the research, rather than predetermined expectations, and to address their intersections amongst multiple layers. This was upheld by the multidisciplinary team of researchers (sociology, public health, psychiatry, psychology, medicine and occupational therapy) together exploring the themes that emerged from different standpoints. While the qualitative approach provides a rich and detailed picture of the specific organisation in the study²⁷ the findings might not be transferable to all settings in which a doctor practises. A multisite case study would allow comparison and validation of the findings and points of difference in other contexts.

There is scope to use the varying data types for a deeper engagement with doctors’ experiences of their daily working conditions and heterogeneity by gender differences, and career stage. This would also provide an opportunity to explore doctors’ personal experiences of mental health and distress so that the structural-level solutions offered herein could be nuanced to offset a broader range of different experiences. For example, research demonstrates that women are assumed to do the majority of care work (emotional labour) consequently patients are more likely to unload mental and emotional content on women doctors, meaning that women doctors carry a disproportionate amount of emotional demand. Gender warrants exploration as a social determinant of doctors’ mental health and is an important area for analytical extension within the dataset.^{28 29} The intersections of gender with other social vectors, for example, experiences of both gendered discrimination and racism on doctors’ mental health, are likewise critical to unpack in further research.

The reliance on doctors to self-select to participate means doctors who experience poor mental health at work might be omitted. While the researchers consulted with the head of department and chief medical officer regarding strategies to remove participation barriers (e.g., discussing the value of the research at team meetings, encouraging senior doctors to volunteer to signal to juniors their encouragement to engage with the research), these doctors might still have been hesitant to participate for fear of being ‘exposed’ as incompetent or as ‘disruptive’ amidst a professional climate that demands excellence and rigorous compliance in the face of challenges. Notably, some doctors opted to only participate in interviews rather than work shadowing to reduce their chances for identifiability. Beyond this study, there is scope to use the methodology for a qualitative case comparison within alternate environments and systems that comprise places and contexts where doctors work, including private hospitals and/or general practice.

Conclusion

This research clearly shows that doctors face a complex web of work and institutional-related factors which compound to threaten their mental wellbeing. It emphasises the need for interventions designed beyond individuals, instead targeting organisational and systemic issues to protect and promote doctors’ mental health. Drawing on evidence anchored in doctors’ own experiences and perceptions and situated within observations of their work environments, this in-depth analysis proposes intervention options as starting points for positive change. These are devised to enhance the overall workplace environment, which emerge from insights about daily routines of doctors in a public hospital setting.³⁰

Our work highlights the risks to doctors’ mental health within a system increasingly driven by profit, compromising the core values of the profession; and extends the work of hospital management into political domains given political (and commercial) processes influence health systems. The study shows how these macro-level shifts potentially discourage medical professionals, leading to a disconnect and loss of meaning, which potentially contributes to burnout and depression. Further research is needed to understand the future implications of these trends on the doctor–patient relationship, colleague interactions, and the overall hospital workforce as well as different geographies of medical practice.

While the study effectively uses the SEM model to capture the nature and extent of interconnected layers of structural challenges that threaten the mental health of individual doctors, some aspects warrant further exploration. In particular, a deeper exploration of the intersections between the layers of impact and doctors’ gender and the potential influence of age and seniority is needed (and planned). The issues outlined herein, regardless, provide critical starting points to creating structural landscapes that better enable doctors’ mental health - in turn, important for effective workforce planning and sustainable patient care.

Data availability statement

No data are available.