Niamh Cahill speaks to Consultant in Child and Adolescent Psychiatry Prof Fiona McNicholas about her research into the high levels of burnout in the area
The long waiting lists for children referred to the HSE Child and Adolescent Mental Health Services (CAMHS) are well recognised.
The matter is often high- lighted in the media, as experts call for greater investment in the service to help address the issue.
The spotlight, however, falls less regularly on the clinicians working within child and adolescent psychiatry and the challenges they face in trying to provide a quality patient service.
Consultants in psychiatry in Ireland can often suffer “moral injury” due to the nature of the services they work in.
In her academic work, Prof Fiona Mc- Nicholas, Consultant in Child and Adolescent Psychiatry at Children’s Health Ireland at Crumlin and the Lucena Clinic, Rathgar, has drawn attention to the issue and related factors.
Prof McNicholas and colleagues have published a number of studies on burn- out in CAMHS and the adult mental health services.
Furthermore, data obtained from an- other larger study on stress levels among doctors in psychiatry during the Covid-19 pandemic is currently being analysed.
Prof McNicholas, who has worked in the Irish mental health service for the past 23 years, began the research to examine the wellbeing of her colleagues due to the concern they were working in an under-re- sourced environment with poor staffing levels and increasing referrals.
Since 2014, referrals to CAMHS have in- creased by about 30 per cent.
“These referrals have been increasing and this has not been met with significant investment in CAMHS,” Prof McNicholas told the Medical Independent (MI).
“There has been a little additional investment, but not much, and we started at a very low level.”
She spoke about the difficult experience of being aware of increasing numbers of children waiting to be seen, and struggling, but not having the capacity, to see them.
“That is damaging to yourself as a clinician trying to do a good job. We talk about that as ‘moral injury’. You want to do a good job, but you can’t for various reasons. It was in that context, where referrals were increasing, and we weren’t getting an in- crease in resources, that I decided to look at the level of burnout in consultants.”
Burnout study
One study, ‘Burnout in consultants in CAMHS in Ireland: A cross-sectional study,’ was published in BMJ Open in 2020.
The results showed that 75 per cent and 72.3 per cent of respondents were suffering from moderate or higher levels of work-related burnout, respectively.
Almost 70 per cent had seriously considered changing jobs and higher burnout scores were present in those who would not retrain in child psychiatry.
“The biggest shock of all was to see the amount of people who thought of not re- training in child psychiatry and that had thought of leaving their job. That’s a huge problem. That’s a bit of an emergency when you have that amount saying they seriously thought of changing jobs in the last six months,” said Prof McNicholas.
The study concluded that “urgent organisational intervention” was required to support the wellbeing of consultant psychiatrists.
Despite the results, Prof McNicholas said neither she nor her colleagues have been consulted by the HSE about their wellbeing in a meaningful way.
Job satisfaction is a major part of recruitment and retention, which is a significant problem within the specialty of psychiatry internationally.
“Recruitment and retention in child psychiatry is a big problem everywhere,” according to Prof McNicholas.
“It’s hard to get psychiatrists to stay in post and to get good job satisfaction. There are many reasons for this.”
These factors include remuneration (psychiatrists generally earn less than colleagues in other medical specialties because there is little private work); poorly resourced services and work environments; and the personal impact of dealing with mental illness.
Regarding the final point, Prof McNicholas said that “if you’re dealing with other people’s problems day-in, day-out, patients are depressed and distressed and have had awful things happen to them, then there is going to be a natural impact on you”.
“Also, sometimes your patients don’t al- ways agree with you despite a helpful consultation; they’re not always happy with you. Whereas if you were going to a cardiologist… they’re generally much happier with you. It’s a difficult practice.”
Other CAMHS staff
Prof McNicholas examined stress and burnout among all staff members in CAMHS in a study published in the Irish Journal of Psychological Medicine in April 2022. It was titled, ‘Occupational stress in clinical and non-clinical staff in CAMHS: A cross-sectional study.’
“The consultant is the leader of the team and absorbs a lot of the stress and has additional managerial and clinical governance responsibilities, but other members are equally exposed,” Prof McNicholas told MI.
“We included secretaries and cleaners because they are often dealing with parents who are frustrated about being on a waiting list. Sometimes the secretaries aren’t properly supported in their role and have never been trained in how to deal with an angry parent.
“What was interesting about this study was that even non-clinical staff were just as stressed in the CAMHS setting.” She said these staff must not be forgotten and are also experiencing burnout.
The survey examined the view of 59 clinical and non-clinical staff. It concluded that “pre-pandemic levels of stress were high among clinical and non-clinical staff surveyed”.
“Given the anticipated increased demand on CAMHS post-Covid-19, urgent action is needed to protect all staff from intolerable levels of occupational stress and burnout”.
Further studies are underway to deter- mine whether “the same stresses have been magnified” because of Covid-19, Prof McNicholas said. Stress levels among psychiatric medical professionals during Covid-19 will be examined in a large national study.
There will also be research undertaken on the stress levels of non-frontline clinicians. It is hoped this will raise HSE awareness of the need to “invest more in looking after staff in their services, be- cause if they don’t, the staff will leave and they won’t have a service”.
Pandemic
According to Prof McNicholas, the problems highlighted in the research have worsened following the pandemic.
“I work in both the community and Crumlin hospital and we are continuing to see the huge increase in referrals,” she said.
“Our staff are getting sick with Covid-related illnesses, but you still have an in- creasing number of referrals. Whilst you’re able to do it in the beginning, this kind of active motivation where everybody was energised, now we’re all depleted as it’s been going on for two years-plus. We’re exhaust- ed. The burnout is getting worse.
Prof McNicholas pointed out that before Covid-19, clinicians “derived solace” from meeting with colleagues at conferences. However, the pandemic saw a reduction in the number of face-to-face events.
“That’s still continued, even though it’s probably not necessary…. I think that’s very detrimental and sometimes you worry that organisations have gotten too lazy and they continue with online because it suits them and they’re not realising the negative side of that and what’s being missed.”
Referrals
The increasing number of children seeking help for mental illnesses is an international trend, according to Prof McNicholas.
She attributes many reasons for the rise, including the use of social media, online bullying, changes in diet, and the fragmentation of families.
“Society has changed and social media has been mentioned as a particular risk factor for kids; the fact you’re continuously exposed to social media and there is no reprieve and adolescents are now wedded to their phones,” she said.
“And it’s all about peer comparison… there’s a lot of self-worth attached to other people’s ratings of you.”
Prof McNicholas also noted the “pervasive” nature of online bullying.
“Before, if you were bullied at school, you had a reprieve when you came home and you could build up resilience. But now the pervasive nature of social media means that’s not possible.”
Prof McNicholas called on the Government to make a commitment to child psychiatry through increased funding and the creation of a more “child-specific focus” in the management of services.
She argued the second priority should be for mental health services to begin to make wellbeing of their staff a priority.
“They should be evaluating that on a regular basis,” she emphasised.
Prof McNicholas pointed out that, de- spite the difficulties, working in child and adolescent psychiatry is still a very rewarding career.
“I am so passionately interested in the wellbeing of children’s mental health that, despite horrendous days, I still delight in being able to meet with the family of a child and feel I’ve made some small difference to the child’s outcome,” she said.
“Despite the hours I work, I love my job. I feel in order to provide a good service to my patients I’m often in the hospital for hours to do that. I give a lot of my time to trainees as well. You could do that 24 hours a day and still feel you haven’t given them enough support.”
Leave a Reply
You must be logged in to post a comment.