Vital Signs in Anaesthesia

This guide is produced by the Association of Anaesthetists in association with the Royal Medical Benevolent Fund

Anaesthetists are high academic achievers with practical skills, the ability to keep calm in a crisis, they have vigilance and tendency towards perfectionism, and they have great team-working and leadership skills. Nevertheless, the Covid-19 pandemic presents a significant challenge for us as it does for the NHS workforce as a whole.

The demand for critical care is unprecedented and requires a huge increase in human effort as well as physical resources. Anaesthetists have many transferable skills but may be unfamiliar with new working environments and feel uncomfortable in new roles, which may include exposure to gruesome scenes, ethical dilemmas, death, loss, distressed patients, families and colleagues.

The challenge of this is set against a backdrop of new (and constantly changing) national and local policies to manage and reduce infection spread.

Anaesthetists in their new roles

Anaesthetists use powerful drugs and techniques every day, with many of their patients being unwell and anxious. We will now work in complex and changing teams throughout the hospital, with different equipment, in different areas and with new policies. Our training, technical expertise, attention to detail, and the culture of safety within the specialty means anaesthesia is generally very safe. In our new roles, these skills will be an asset, but the risks of poor outcome and potential lack of resources will be a significant change.

The joy of working as an anaesthetist often comes from providing a sense of calm and control in fast moving clinical scenarios. Clinical work is generally on a one-to-one basis with patients, meaning we can give high quality care and be in control, at least during the time in theatre. Factors promoting work satisfaction include patient contact, the privilege of enabling a good patient outcome, and strong support at home and work [1]. In new roles, patient contact while wearing personal protective equipment (PPE) will feel more distant, outcomes may not be good, and changes in work pattern and stress may challenge support at home and work. The need to don PPE before entering a room to provide lifesaving treatment is essential. The potential delay this may cause to starting treatment could be difficult for the anaesthetist, but our safety is key to our own wellbeing and our ability to treat other patients.

What’s different about anaesthetists?

Stressors for anaesthetists include demanding clinical and non-clinical workloads, exhaustion from multiple commitments, feeling ‘on edge’ (and, perhaps, even unsafe) at work, and the changing way society sees doctors [1]. This is likely to become an increasing pressure during the current pandemic. Stress and burnout increase fatigue amongst anaesthetists [2-4]. Fatigue reduces mental and physical performance and impairs alertness [5], which are core to the calm and controlled approach required and are cherished by anaesthetists. We are expected to carry on and there may even be a sense that seeking help is a sign of weakness.

What’s the same in anaesthetists?

During this pandemic, all doctors will have to deal with difficult situations and take great responsibility, often with little support. They are not omnipotent. They are fundamentally the same as everyone else and have the same needs. All doctors have their own personality, quirks, fears, phobias, likes, dislikes and ways of coping with stress and conflict. Their personas may be armoured to cope with the job, but they will be feeling the full range of human emotions too. If these are unbearable, or just difficult, they can be suppressed. In this case, doctors may not be consciously aware of these emotions, but they are still there.

All doctors at times feel anxious, frightened, depressed, deluded, suspicious, bad tempered, irritable, bored, martyred, unappreciated, bullied, tired, taken for granted and every other emotion. Just like everyone else.

Staying well

The ‘ABC’ of wellbeing are: ‘autonomy’, ‘belonging’, ‘competence’, and are useful for anaesthetists in improving the work environment at this time [6]. Working conditions will be difficult but can be improved by thinking about everyone’s practical needs.

Autonomy is the most important of the three needs that must be met in the workplace [7]. The key workplace factors that impact on autonomy and control are voice and influence in a just workplace, the right work conditions, and manageable and predictable work schedules and rotas. ‘Voice’, ‘Influence’ and ‘Fairness’ can be improved by involving all team members in improving working conditions. The public and many businesses have been very generous with donations, and encouraging staff to access such support can make the whole team’s working conditions better. Rotas and work schedules should try to take into account the skill mix within the team and help to protect the vulnerable as much as possible without overburdening those perceived as ‘strong’.

A sense of belonging is created by strong teamwork, and this pandemic is an opportunity to strengthen that as we work together. Training together in preparation will help that sense of belonging. The best leaders will rise to the top during this crisis.

To feel competent the workload needs to be manageable. It is likely that it will be unmanageable, and we will need to find ways to step away and relinquish responsibility for a situation that is not of our making. A more population-based approach to healthcare delivery may emerge where we recognise that by taking on too much we increase the risk of sickness and put further strain on the remaining colleagues.

We all need to feel supported and kind words can go a long way for all team members when the teams are under strain. Supervision is going to be challenging and may require a change of mindset to being ‘good enough’ which will be difficult for the perfectionist. Training in teams (skills and drills) will be invaluable. Learning lessons, training and development are highly developed skills of an anaesthetist and having a simple mechanism for feeding back about practical issues (for example, access to food) and clinical issues that occur will help alleviate stress. Peer support and clear signposting to support services will be essential.

Mental hygiene

On a good day, working as an anaesthetist is rewarding and enjoyable, but there will be less-good days when we face significant challenges. So often we only consider our wellbeing when things are not going so well. This may become the new normal in this pandemic. Many problems related to wellbeing are related to organisational factors but there are still individual strategies we can use to support ourselves. Much is made of ‘resilience’ and individuals can be made to feel deficient if they ‘lack resilience’ during a challenging time.

A recent editorial in Anaesthesia [8] refers to the three Cs of personal resilience: control what you can; cope with what you cannot control; and, concentrate on what is important. In our work we can only control the ‘controllables’. Trying to control the ‘un-controllables’ is futile and stressful; we can only hope to cope.

A Physician Wellness Hierarchy has been proposed [9]. It makes the point that ‘it is hard to benefit from resilience courses or meditation if we are dehydrated, depressed, or scared for our physical safety’. Attending to basic physical and mental needs is the first step to improving wellbeing. The key is to develop a good degree of self-awareness and recognise when we are overstretched and overstressed. Under pressure we need to adopt strategies that improve our resilience and performance. Stacey proposes some strategies in a toolkit which addresses and highlights sleep, exercise and meditation [10].

Suicide appears to be more prevalent amongst anaesthetists. A recent survey highlighted the considerable emotional and mental burden of suicide on anaesthetists [11]. We do not know what the impact of the pandemic will be.

Burnout and compassion fatigue in anaesthetists

Burnout – ‘a syndrome resulting from chronic workplace stress that has not been successfully managed’, is a recognised occupational phenomenon and included in ICD-11. Compassion fatigue has similar symptoms to burnout and describes a secondary traumatic stress disorder affecting those involved in situations where they are exposed to a traumatised individual.

Burnout is characterised by:

emotional exhaustion – feelings of emptiness and emotional blunting
depersonalisation – increased mental distance from or feelings of negativism or cynicism related to one’s job
reduced professional efficacy – doubts about personal and professional effectiveness

Symptoms of compassion fatigue include:

re-occurrence of nightmares and flashbacks to traumatic event
excessive blaming
compulsive behaviours
excessive complaints about administrative functions

National surveys and research in this area confirm the problem in physicians [1, 2, 12]. Specific factors identified for anaesthetic trainees at high risk of burnout include high levels of additional non-clinical workload and little or no regular exercise. This is in addition to more generic factors recognised to affect all doctors and medical students, including workload, control, reward and recognition, community support, fairness and values. A sense of autonomy in our roles seems to be protective. Male anaesthesia trainees are at increased risk of burnout, with female trainees reporting higher stress levels. There have been numerous calls for action in this area in medicine and in anaesthesia [12, 13].

Recognising the symptoms and signs of doctors in difficulty

Under pressure we often lose our sense of perspective and cannot always rely on subjective feelings. The list below has been devised for trainees but could apply to all doctors [14].

Symptoms and signs of doctors in difficulty

the ‘disappearing act’: not answering bleeps, disappearing between clinic and ward, lateness, frequent sick leave
low work rate: slowness in doing procedures, clerking patients, dictating letters, making decisions, arriving early, leaving late and still not achieving a reasonable workload
‘ward rage’: bursts of temper, shouting matches, reacting badly to real or imagined slights
rigidity: poor tolerance of ambiguity, inability to compromise, difficulty prioritizing, inappropriate ‘whistle blowing’
‘bypass syndrome’: junior colleagues or nurses find ways to avoid seeking the doctor’s opinion or help
career problems: difficulty with exams, uncertainty about career choice, disillusionment with medicine
insight failure: rejection of constructive criticism, defensiveness, counter-challenge

Family, close friends and colleagues may provide feedback as well as support, though sometimes it is hard to hear it. They may notice changes in behaviour, such as irritability, drinking more or withdrawing before you are aware of them. Raising awareness of stress, burnout and compassion fatigue is essential to tackling these issues. It is well known that doctors can be reluctant to seek help, so it is imperative we look out for our colleagues.

When we are involved in or witness traumatic scenes we often cope by ‘shutting down’. This is a defence that makes the situation bearable, but it is healthy to be aware that this happening.

Seeking help

Anaesthetists can be reluctant to seek medical help, for both physical and mental health. There can be a temptation to catastrophise, or to medicalise problems, and to self-treat or self-medicate. During the pandemic it is a duty to try to stay well, but also not to work if we are not fit. Rather than diagnose the problem or decide for ourselves the appropriate specialist or course of treatment, it is much more useful to allow yourself to be the patient and not a doctor. Your GP can provide a first point of contact and co-ordinate action. We should allow ourselves to be patients, without additional expectations.

Equally we should treat any colleague seeing us similarly. Anaesthetists may have concerns around confidentiality, and the stigma around illness. However, we are merely mortals, subject to the same illnesses as everyone else. Aside from statutory responsibilities or serious threats to patient safety, the same rules of confidentiality apply.

Helping ourselves

There is no doubt that being an anaesthetist is a stressful job. Many pressures build up due to organisational factors over which we have little control and are hard to address. Despite this, there are some simple protective steps we can take to help ourselves:

Intellectual interest

Staying interested and involved in the job can make it more engaging and rewarding.

Time management

It is important to be realistic about what can be achieved in the time available. It can be useful to work out what your values and goals around work-life balance are.

Self-awareness

It is helpful both inside and outside of work to be aware and reflective of what we are doing. Being realistic about what we can achieve, and our own strengths and weaknesses can reduce some of these stresses and frustrations.

Support

It is vital that we all have support networks, from colleagues, team members, friends and family.

Sources of help

Sometimes prevention, self-care and support from our colleagues, GP, friends and family aren’t enough and we need to ask for extra help. It is not a sign of weakness but of maturity and self-awareness.

Details about the Association of Anaesthetists, the RMBF, and other sources of help and information are below.

How the Association of Anaesthetists can help

The Association of Anaesthetist represents the life-changing, life-saving profession of anaesthesia – by supporting, informing and inspiring a worldwide community of over 10,000 members. Our work and members span the globe, yet our voice is local and personal. We stay in close contact with our members, look after their day-to-day wellbeing, and act as their champion. Our world-class conferences, journals and online resources educate and inform, and our respected guidelines continually improve standards of patient safety. We preserve and learn from the history of anaesthesia. We use that to inform the present, and facilitate vital research and innovation into its future. As an independent organisation, we speak up freely and openly for the interests of anaesthetists and their patients. We influence policy, raise public awareness and are at the forefront of safer anaesthesia, across the world.

Homepage

Wellbeing & support

Association of Anaesthetists is the brand name used to refer to both the Association of Anaesthetists of Great Britain & Ireland and its related charity, AAGBI Foundation (England & Wales no. 293575 and in Scotland no. SC040697).

How the RMBF can help

If you are a doctor, and you are facing financial hardship as a result of illness, injury, disability, bereavement or age, you may be eligible for financial support from the RMBF.

We also offer:

Other sources of help

Academy of Medical Royal Colleges: Support for doctors

The British Medical Association – Counselling and peer support services

Free and confidential 24/7 counselling and peer support services open to all doctors and medical students (regardless of BMA membership), plus their partners and dependents.

NHS Practitioner Health Programme

A free confidential service for doctors and dentists with issues relating to a mental or physical health concern or addiction problem, in particular where these might affect their work.

Intensive Care Society Wellbeing Hub

An excellent wellbeing resource library written by Dr Julie Highfield, clinical psychologist

Health Education England: Covid-19

General Medical Council: Coronavirus

Contributors

Thomas James, Chair, SAS Committee, Association of Anaesthetists

Mike Nathanson, President Elect, Association of Anaesthetists

Lucy Powell, Elected Member, Association of Anaesthetists Trainee Committee; ST6 Anaesthetics, Northern Deanery

Robert Self, Elected Member, Association of Anaesthetists; Consultant Anaesthetist, The Royal Marsden NHS Foundation Trust

Tei Sheraton, Honorary Membership Secretary, Association of Anaesthetists; Consultant Anaesthetist, Aneurin Bevan University Health Board

Karen Stacey, Elected Member, Association of Anaesthetists Trainee Committee; Locum Consultant Anaesthetist, Imperial College Healthcare NHS Trust

Richard Stevens, Associate Director and Coach at the Thames Valley Professional Support Unit; Trustee, Royal Medical Benevolent Fund

Supported by

Nicola Heard, Head of Education and Membership Services, Association of Anaesthetists

Kate Bresler-Jones, Head of Volunteering, Royal Medical Benevolent Fund

Download this guide

Vital Signs in Anaesthesia (.pdf)

More guides in this series

The Vital Signs: a guide for doctors seeking help and advice

The Vital Signs in Primary Care

The Vital Signs for Medical Students

Returning to Medicine: a Vital Signs guide

References

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