Olivia Jagger, Masters Candidate, Harvard T.H Chan School of Public Health; GP, ACF Wessex

Published in JHH13.3 – Saving the NHS

I became a doctor at a time of significant change in the NHS. Excessive workloads and pressures on service provision created a challenging training environment.Working in the ‘thick of it’ ignited my passion to improve the systems I work in. Not only to improve patient care and experience, but importantly the working environment and experience of my colleagues. I completed the National Medical Director’s Clinical Fellow Scheme to understand the ‘bigger picture’ of NHS and how to influence the system from within. Building on this, I am combining training in general practice with research into resilience training for doctors.

To feel joy in work you need to: appreciate meaning and purpose; feel safe and have job security; have some choice and control over your time; experience camaraderie with colleagues; have career flexibility and opportunity to… Click To Tweet

Introduction

Sadly, for many junior doctors working in the NHS, the joy has gone from their work. I deliberately talk about joy in work, not mere satisfaction Why? Doctors who feel joy in work feel happier and more secure, have greater job satisfaction and greater career fulfilment. As a knock-on effect, they deliver higher quality patient care, are more likely to remain in the workforce and more likely to engage in health[1]care improvements (West 2013a). For the NHS to continue to deliver excellent healthcare, it needs to retain a happy, fulfilled and engaged workforce who are committed to delivering high[1]quality care, even in stressful times. Bringing back joy in work is not only important for junior doctors’ survival, but is vital for the long-term survival of the NHS. One of the first people to speak about the concept of joy in work was the American engineer W. Edwards Deming. Deming promoted the idea that every employee should be able to achieve joy at work and that this joy would lead to improved quality and higher organisational performance. The Institute for Healthcare Improvement has led the way in applying this concept to healthcare, advocating joy in work as a resource for excellence and a driver for improvement in healthcare.

Unfortunately, many factors are diminishing joy in work for junior doctors. The working environment in the NHS is tough, with excessive workloads and increasing demands on service provision, which presents a challenging training environment. There is currently a highly conflictual atmosphere in the NHS and many in the workforce are demoralised. The recent contract dispute left junior doctors feeling distressed, under[1]valued and worried for their futures. Frequent healthcare and training reforms create uncertainty and make it challenging for junior doctors to imagine what their future practice might look like. As a consequence, many of these highly skilled future NHS workers are thinking with their feet and leaving the NHS. In 2015, 48% (over 3,400 junior doctors), did not continue to specialty training after successfully completing the founda[1]tion programme (UKFPO 2015). In the wake of the contract dispute, it is predicted that greater numbers of junior doctors intend to work abroad or leave a career in medicine entirely. For junior doctors to survive, there is a need to bring back joy in work.

Finding joy in work

The best indicator for me that I feel joy in work is when I look forward to going to work in the morning. There are a few simple actions that can bring back joy in work, which most junior doctors will identify with, but it is an individual experience. Reflecting on different jobs that you have had, both positive and negative experiences, is an easy way to identify the factors to focus on that bring you the most joy in work.

Re-finding meaning and purpose

A study by Deloitte highlighted the connection between joy and meaning in work: ‘Free food and ping-pong tables are fun perks, but companies that succeed in having highly engaged employees focus intently on driving meaning, purpose, and passion among workers’ (Deloitte 2016). Most doctors enter a career in medicine to help others and make a difference. Although prestige, money and academic stimulation may have a role, the opportunity to care for patients at their most vulnerable and share in intimate moments in their lives is the real privilege of being a doctor. We have all experienced joy in work, be it a memorable encounter with a patient or being part of a really good team who became your great friends. Unfortunately, what it is to be a doctor is changing and the opportunities for having the kind of moments that doctors find most professionally satisfying are diminishing, as patient encounters become briefer and team structures less stable. To feel joy in work, junior doctors need to appreciate meaning and purpose in work. It takes time or effort to experience moments that count but not all that much: I have found that making a conscious effort during busy on calls to get to know something personal about my patients lives can really turn a shift around.

Take back control and build resilience

A study of doctors in Sweden found the three strongest predictors for work-related illness are high workload, lack of control and lack of social support at work (Wilhelmsson et al 2002). The working environment in the NHS can be tough and, with high patient volumes and long working hours, the job is undeniably pressured. Junior doctors don’t have much autonomy in their roles: we constantly move around, have little control over rotas and we often experience work/home conflicts. You need to have some choice and control over your work to feel joy in work. Simple things, such as more effectively managing your time and prioritising jobs, can allow you to take back some control and not feel overwhelmed at work. Importantly, to survive it is necessary for junior doctors to accept that we are not infallible. Doctors are high achievers and don’t respond well to failure, but medicine is complex and full of uncertainty, the workload is intense and the environment can be chaotic. The only thing guaranteed is that we will make mistakes. Having a supportive team to stand by you, buffer stress and help you learn from mistakes is important. These shifts in attitude and self-management are personal resilience skills that can help us thrive, not just survive, in this challenging working environment, and boost joy in work.

Play to your strengths and pursue your interests

Playing sport does not make me happy. Sewing does not make me happy. Why? Because I am not very good at either of those activities. Cooking, on the other hand, makes me very happy (I like to think of myself as a semi[1]decent cook!). We all enjoy things we are good at and that interest us. Having the opportunity to pursue, develop and use your strengths brings joy. In work, take account of the skills mix of your team and play to your strengths. Throughout your training make your area of clinical interest known to your team and seize opportunities to develop your skills or pursue an area of special interest. You will find this personally and professionally rewarding.

Value and appreciate one another

Cows that have names and are treated as individuals produce 500 pints more milk a year. Junior doctors are no different! (Douglas, Rowlinson 2009) When doctors feel valued they are happier, work harder, deliver higher quality care and put in discretionary effort over and above their core responsibilities to improve the systems they work in (West 2013a). Sadly, many junior doctors do not feel valued, and this diminishes their joy in work. They are required to work erratic and frequent on-calls and have to rotate around large geographical areas with little regard for their family lives. Unlike other industries, there are few ‘perks’ to the job. The free parking, meals and housing junior doctors used to enjoy have long since gone.

All these little things may seem inconsequential but make junior doctors feel less valued. Importantly, it is not about money. This was highlighted by the recent junior doctors contract dispute. Patient safety aside, the key issue was not that junior doctors were demanding more money but that they want to feel valued, to be fairly compensated for the work they do and to be treated equitably. Undeniably there is need for change at a national, organisational and local training level to ensure junior doctors feel valued in their work, training and personal lives. However, simply working in a mutually appreciative team, in which you feel valued, will increase your job satisfaction (West 2013b). It only takes a few moments to appreciate your colleagues by encouraging them and thanking them at work, but this can have a big impact.

Look after yourself and support each other

I was amused the other day by a ‘tweet’ of a picture of Maslow’s hierarchy of needs with the addition of wifi at the base of the pyramid – a wry and apt reflection on modern life. Joking aside, Maslow’s hierarchy (Maslow 1943) is a concept that all doctors are familiar with yet all too often they overlook their own basic needs. To reach the higher levels and feel joy in work, you first need to feel safe, both physically and psychologically, and attend to your basic needs. Junior doctors often overlook the basics, not taking time to eat, drink, rest or go to the toilet during busy shifts. Taking care of the other areas of our lives such as exercise, nutrition, sleep and social connections is as important. Your job should not be the be all and end all. There are many other areas of your life in which you find joy and every junior doctor can benefit from learning some self-care strategies. Establishing security in your working environment is also important. We all derive joy from strong social networks. Collaborating with colleagues and experiencing camaraderie creates a safer, supportive and positive working environment. Taking a few minutes each day to talk with colleagues about their lives is an easy way to boost team morale and increase joy in work.

Be positive

Times are tough for junior doctors and the challenges facing the NHS may seem insurmountable. In these times it can be easy to fall into the mode of learnt helplessness, but the power of thinking positively should not be under[1]estimated. If you are optimistic and think positively you feel happier than people who are pessimistic or feel helpless. Walt Disney built his career on spreading joy. It is Disney company policy that you cannot pass a colleague in the corridor without greeting them with a smile (Lee 2004). The act of smiling itself makes you happy! A study found that when you ask people to place a pencil in between their teeth, which forces them to activate the facial muscles used to smile, they find cartoons funnier (Soussignan 2002).

Even more powerfully, joy, like smiling and laughing, has a viral property – it can be cultivated and it is contagious. A study has shown that happiness spreads from person to person to person in a chain reaction through social networks (Fowler, Christakis 2008). Therefore, positive behaviors like smiling and being optimistic, which make you feel happy, pass from person to person and can create joyful working environments. The same is true of negative behaviors, if one person is having a bad day it can drag down the whole team. It is therefore important to take responsibility for your own happiness because it affects everyone around you. Can you imagine the ripple effect of spreading joy if Disney’s policy was adopted across the NHS?

Conclusion

Many junior doctors currently feel that they are just hanging in and surviving. But bringing back joy in work can move you from merely surviving to thriving once again in your work. Joy in work is not just important to individual doctors. For the NHS to survive in the face of new challenges it needs a happy, fulfilled and engaged future workforce. Key to junior doctors surviving in the NHS is ensuring that they enjoy their work, that they feel valued again and that they take back some control over their work lives and future careers.

We shouldn’t be passive in letting change happen to us. The junior doctor contract dispute united junior doctors and demonstrated that together we have a loud voice and can be powerful influencers. A positive outcome of the dispute would be for junior doctors to continue to engage in and influence debates about the future of the NHS, especially workforce issues and training issues, and to ensure the future NHS is one that we enjoy and want to continue working in. The wellbeing of junior doctors is the shared responsibility of individual doctors, training programme directors, healthcare organisations and the government. But there are many simple things we can do for ourselves and colleagues right now to bring back joy in our work.

A junior doctor colleague shared her mantra with me: ‘gratitude is the new attitude’. If we can all be kinder to one another it can make the working day much more enjoyable. Emotions are catching. Be aware that how you feel is having a real impact on others, and you may be able to spread positive feelings that could lift the whole working environment. It all starts with a smile. Who you are matters!

References

• Deloitte Global Human Capital Trends 2016 report. Online. Available at: www.bersin.com/uploadedFiles/hc-trends-2016.pdf?aliId=76051297 (accessed 4 November 2016).
• Douglas C, Rowlinson P (2009) Exploring stock managers’ perceptions of the human-animal relationship on dairy farms and an association with milk production. Anthrozoos 22 (1) pp 59–69.
• Fowler J, Christakis N (2008) Dynamic spread of happiness in a large social network: longitudinal analysis over 20 years in the Framingham Heart Study. BMJ 337 (2338) pp 1–9.
• Lee F (2004) If Disney ran your hospital: 9 1/2 things you would do differ[1]ently. Bozeman, MT: Second River Healthcare Press.
• Maslow H (1943) A theory of human motivation. Psychological Review 50 (4) pp 370–396.
• Soussignan R (2002) Duchenne smile, emotional experience, and autonomic reactivity: a test of the facial feedback hypothesis. Emotion 2(1) pp 52–74.
• UK Foundation Programme Office (UKFPO). F2 Career Destination Report 2015. Online. Available at: file:///C:/Users/User/Downloads/F2_Career_Destination_Report_2015_- _FINAL.pdf (accessed 4 November 2016).
• West M (2013a) Promoting a culture of high quality care. Online. Available at: www.kingsfund.org.uk/leadership/promoting-culture-high-quality-care (accessed 4 November 2016). West M (2013b). Compassionate care means rooting out staff stress. Online. Available at: www.hsj.co.uk/comment/compassionate-care-means-root ing[1]out-staff-stress/5065611.fullarticle (accessed 4 November 2016).
• Wilhelmsson S, Foldevi M, Akerlind T, Faresjou T (2002) Unfavourable working conditions for female GPs. A comparison between Swedish general practitioners and district nurses. Scandinavian Journal of Primary Health Care 20(2) pp 74–78.