Stress in vet professionals: Sometimes we're just not as cool as cats

This is article thirty in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

As Jen walked into theatre her hands still dripping with soap, it struck her how unreal this all felt – there was Lucy the Rottweiler, on her back completely anaesthetised with a bright red tube sticking out of her mouth. There was Martin, the clinical director, his hair sticking up at odd angles, snapping on a pair of gloves. And finally, Selina the head nurse, wearing a cocktail dress and a pair of old trainers.

"Come on, come on," Martin said flatly, not bothering to look up. Jen’s dream bubble burst. This out-of-hours shift was definitely happening.

"P, perhaps we should do the surgical checklist?"

"No time. Remember I must be out of here by 6am. Taking the parasite to the airport."; Jen assumed he was referring to his son.

They started work on Lucy’s GDV, cutting through her shaved skin and untwisting the awkward stomach. To Jen’s surprise, she noticed that Martin’s hands visibly shook as he tried to place sutures. He was sweating too,

"Hold this, yes," he would say. "No, not that you dummy. Here, here!"

45 minutes later and they were ready to close. Selina held the clipboard up,

"Erm, perhaps we should count the instruments and swa…"

"No time, remember what I said?"

They worked on in silence and at the end exchanged brief glances. Martin breathed out,

"OK, well, thank god that’s over."

After changing Jen popped back into theatre, Selina was on the floor counting a large heap of bloody swabs,

"S**t Jenny, I think we are one short."

At that moment Martin appeared, bag and car keys in hand,

"Well, just assume the nurse mis-counted when she was packing the kit alright?"

"But Martin," Jen said, the lack of sleep was right behind her eyes now, "what if the nurse hasn’t? There’s still a swab inside."

"Well, it’s too late then isn’t it?! I’ve got to go." His voice was breaking, he looked almost frantic as he checked his watch. "Remember, you’re on morning consults." And with that, he left.

Workplace stress

In healthcare the subject of work-place stress has been contentious for some time: some assert that clinicians should be able to control their anxieties irrespective of the scenario - like the one Martin found himself in – surely conscientious, intelligent clinicians can ‘keep calm, and carry on’? Just ‘think positive,’ and ‘work the problem’. Others take a different view and argue that stress can strike anyone at any time irrespective of professional status.

Leaving that argument aside for a moment, let's look at some of the statistics, and define what stress is – fortunately there is a lot of evidence that can help shine a light on this murky and complex topic.

Stress can be defined as ‘the psychological and physical state that results when the resources of the individual are not sufficient to cope with the demands and pressures of the situation¹, and it affects up to 45% of veterinary professionals according to one recent survey².

Stress response

In people the ‘stress response’ is a complex interaction between our central nervous system and a group of hormones. This system causes changes in our body, and mind. At low levels of activation – for example, during a moderately busy day – and if the degree to which the system is ‘switched on’ doesn’t feel overwhelming, that person can be said to be experiencing ‘eustress.’ Eustress enables us to work effectively and to meet time-bound goals. But when we feel out of control, out of our depth, or threatened in some way at work, the stress response floods our circulation with much higher quantities of these hormones - we can start to experience various physical symptoms including a pounding heart, and fast breathing. Our chest, and neck muscles may tighten, or we might start to sweat. While a body primed for ‘fight, or flight’ might be highly appropriate if we are suddenly confronted by a testy woolly mammoth, this cognitive and somatic state is less well-suited to many of the scenarios faced in modern work and if repeatedly experienced, can lead to chronic physical and mental health disorders³. In many ways, we are mal-adapted for a work life that inadvertently makes us feel like we are back on the snowy planes, or grass lands of our ancient ancestors.

Other symptoms that we might see in a stressed colleague (or recognize in ourselves) are:

• headaches, loss of appetite and nausea (physical).

• difficulty concentrating and reduced problem-solving ability (cognitive).

• irritability, depression and fatigue (feelings).

• withdrawing, aggression, tearfulness, uncommunicativeness (behaviour)¹.

But there is evidence to suggest that individuals differ somewhat in their vulnerability to stress, and that those with fewer coping skills and low self-esteem are more likely to experience it. It has been proposed that people with ‘Type A’ personalities are also generally more inclined to stress¹, where Type A personality defines someone who is ambitious, competitive, impatient and sometimes even neurotic⁴. Approximately 33% of human doctors are believed to fit this description⁵.

Of course, many aspects of veterinary work are by nature, stressful to some extent. These include treating patients that have emotional or financial significance to an owner, performing complex tasks under time pressure, the act of euthanasia and the danger of animal-inflicted injury⁶. But the literature also points to the relevance of unpaid over-time, work over-load, a lack of autonomy, and an absence of what might be called fairness in work^1,7.

Finally, moral distress is increasingly believed to play a role in the wellbeing of healthcare professionals. Moral distress is a sense of unease at work when we observe or have to participate in a course of action that is at odds with our belief system. Common scenarios would include a client that is unable to afford care that would help their pet, or witnessing any procedural transgression which runs counter to an ethical framework⁸.

Alarmingly, one study found that the presence of a core subset of work-place stress factors increases the risk of poor health outcomes in employees to the same level as breathing in second hand tobacco smoke. We can therefore conceptualise excessive workplace stress as an invisible pathogen that can cause major ill-health and something that well-being apps, and breathing exercises are relatively ineffective against⁷.

What about Martin?

Martin’s behaviour in the theatre could be described as rude at best. His disregard for a surgical safety checklist might have put the welfare of his patient in jeopardy. But he was in all likelihood stressed as well. The causes of his stress probably fall into more than one category – personal struggles with confidence and a busy home life perhaps being two. Work factors, though, would have included long hours (possibly unpaid), the expectations of his client and perhaps other organisational cultural factors that we can only guess at (see above).

But workplace stress can be mitigated against, and in the next blog we will explore some ways of caring for, and improving, the well-being of, workers who care.

With thanks to Laura Playforth BVM&S MSc Adv HCP (Open) MRCVS, for thoughts and comments.

Checklist- What you can do next

• Read the next article in this two part QI Feature on Stress in vet professionals: How to regain your cool to discover the innovative strategies and practical approaches that can help prevent the build-up of stress in practice.
• Read our previous QI Feature Compassion - at the heart of practice to find out how compassion can be a powerful team behaviour for improving care quality, communication, teamwork and wellbeing, in turn helping to reduce the incidence of stress and burnout.
• Research by the Institute of Healthcare Improvement shows that improvements in how we feel – and work – are possible in even the most pressured circumstances. RCVS Knowledge has developed a set of structured resources to support veterinary teams to improve the contentment and buzz they experience in work, based on the Institute for Healthcare Improvement’s tried-and-tested Joy in Work framework. Access the What Matters to You? tools and resources to find out how asking all members of a team what matters to them can help us gain a comprehensive understanding of what lies beneath our combined commitment to the best possible care.
• Access our CPD course Using QI tools for patient safety - Checklists and more to discover the attributes that make checklists effective in helping us communicate effectively as a team to deliver safe, quality care even while performing complex tasks under pressure. Our free to access QI Boxset is available in bite sized episodes to help you structure safety checklists to suit your setting.
• Checklists are also there to support your teams. Have a look at the RCVS Knowledge rolling-take-5 checklist adapted from the NHS England 'Going home checklist' to see the steps we can all take at the end of a busy day to safeguard our wellbeing.
• Having the ability to discuss challenging decisions around complex cases can help to reduce the incidence of moral distress. Read our previous QI Feature What matters? Is a change in how we provide care needed? to find out more about an approach to case management that considers the patients circumstances and the needs and values of their care-givers and owners. Download the Conversation guide for delivering contextualised care to help veterinary teams identify any areas of support that the pet owner may require when treating their pet.
• Download the RCVS Knowledge Surgical Safety Checklist Manual, detailing how surgical safety checklists can be used to improve patient safety within practice. Developed following research undertaken into Quality Improvement within the veterinary industry, this manual includes examples and testimonials from a variety of practices and organisations to help with the development and implementation of your surgical safety checklist.

References

1. Michie, S. (2002) Causes and management of stress at work. Occupational and Environmental Medicine, 59 (1), pp. 67–72. http://dx.doi.org/10.1136/oem.59.1.67
2. Stress and burnout top vet concerns six months on from Covid lockdown (2020) [BVA] [online]. Available from: https://www.bva.co.uk/news-and-blog/news-article/stress-and-burnout-top-vet-concerns-six-months-on-from-covid-lockdown/ [Accessed 11 September 2023]
3. Understanding the stress response (2020) [Harvard Health Publishing] [online]. Available from: https://www.health.harvard.edu/staying-healthy/understanding-the-stress-response [Accessed 11 September 2023]
4. Friedman, H.S. and Booth-Kewley, S. (1987) Personality, Type A behavior, and coronary heart disease: The role of emotional expression. Journal of Personality and Social Psychology, 53 (4), pp. 783–792. https://doi.org/10.1037/0022-3514.53.4.783
5. Louwen, C., Reidlinger, D. and Milne, N. (2023) Profiling health professionals’ personality traits, behaviour styles and emotional intelligence: a systematic review. BMC Medical Education, 23, no. 120. https://doi.org/10.1186/s12909-023-04003-y
6. Cevizci, S. et al. (2014) Occupational stress and risk factors in veterinary surgeons. Kafkas Universitesi Veteriner Fakultesi Dergisi, 20 (1), pp. 41-48. https://doi.org/10.9775/kvfd.2013.9426
7. Goh, J., Pfeffer, J. and Zenios, S.A. (2015) Workplace stressors & health outcomes: Health policy for the workplace [Harvard Business School] [online]. Available from: https://www.hbs.edu/faculty/Pages/item.aspx?num=50306 [Accessed 11 September 2023]
8. Fawcett, A. and Mullan, S. (2018) Managing moral distress in practice. In Practice, 40 (1), pp. 34–36. https://doi.org/10.1136/inp.j5124

About the author

Mark Turner BVSc MRes MRCVS

Mark graduated from the University of Liverpool in 1996 and in 2017 completed a Masters degree at the RVC investigating patient safety culture in the UK veterinary professions.

The research project investigated contemporary knowledge of patient safety behaviours in practice including significant event reporting and auditing.

He has an interest in the application of patient safety as a tool for improving staff engagement and success. He has written for Vet Times, Companion magazine and appeared as a guest blogger for the BVA/RCVS Vet Futures project.

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