Key words : Coronavirus disease 2019, Health care worker, Posttraumatic stress disorder, Psychological health

Exposure to death and suffering is a predictable feature of a career in health care, which may have a cumulative negative effect on the caregiver. Various factors can mitigate this, such as the meaningfulness of the work itself, cohesive teamwork, a clinician’s own resilience, organizational coherence, and access to safe spaces to debrief and process the emotional intensity of the work. Without these mitigating factors, health care workers can be at risk of burnout, an occupational phenomenon defined by the World Health Organization in the 11th Revision of the International Classification of Diseases (ICD-11) as a state of energy depletion or exhaustion, increased mental distance from one’s job, and reduced professional efficacy.¹ Before this ICD-11 definition was established, burnout was most commonly referred to in the literature as a state of depersonalization, emotional exhaustion, and a sense of reduced achievement. All of these features pose risks not only to the individual clinician but also to the efficacy of teamwork and ultimately to patient care.

Furthermore, if an individual caregiver is unsupported, there is a significant risk to their mental health, and issues such as posttraumatic stress disorder (PTSD), depression, substance abuse, and suicide are seen across different medical specialties.^2-5 The risks are significantly higher for physicians compared with the general working population⁶ as well as nonmedical academic professionals.⁷

Despite this background, the culture of medicine has embedded a tendency for clinicians to overlook their own psychological health needs, often ignoring early warning signs. Traditionally, health care organizations have not been proactive (ie, occurring regularly and not simply because an individual or team is in crisis) to provide psychological and emotional support for clinicians as a routine element of the working culture and to encourage a healthy “work-life balance.” The consequent impairment of clinical performance adversely affects both parties and most significantly could result in patient harm.⁵

In transplant-related care, these challenges may be magnified. The complex and comprehensive care provided during the transplant patient’s perioperative pathway is certainly stressful to the wide range of transplant professionals involved in this process. The inherent risks of the transplant procedure together with the complex process of deceased and living donation add to the emotional stress of the clinician, albeit these challenges are offset by the meaningful and the lifesaving nature of the work.

However, an adverse outcome at any stage may negatively affect not only the recipient but also the donor, the donor’s family, the health care team, and potentially the transplant community at large. Therefore, the burden of responsibility on transplant health care professionals should not be under­estimated.

The coronavirus disease 2019 (COVID-19) pande­mic has threatened the success and sustainability of transplantation worldwide in 2020 and has increased the pressure on the health care workers who have already been facing significant psychological challenges.⁸ With the high mortality in transplant patients infected with COVID-19,9,10 these challenges have been magnified. This paper addresses the challenges to the mental well-being and psychological health of health care providers, both generally and within the transplant sphere, highlights some of the inadequacies, and proposes strategies to establish psychological interventions that could benefit health care professionals in transplantation.

Burnout is a regular occurrence in physicians caused by the effects of extended hours of work, witness to human illness and suffering on a daily basis, challenges to their personal balance for work versus life outside of work, delayed gratification, and the administrative aspect of clinical work that regularly displaces physicians away from patient care. A recent study demonstrated that that more than half of physicians met the criteria for burnout; disturbingly this had increased by 10% between 2011 and 2014.⁶ It is unclear whether this trend represents a real increase or simply a greater awareness of the problem, but the consequences of burnout are severe, including substance abuse,² disruptive behavior, absenteeism,¹¹ divorce,¹² depression,¹³ and suicidal ideation and suicide.¹⁴ Importantly, patient care and safety can be compromised as a direct or indirect effect of these consequences.

Unfortunately, the culture within medicine and the fear of the negative professional consequences may create a difficult challenge to screen and identify those health care providers who may be at risk for burnout. Historically, very few physicians sought help in the setting of burnout, especially when this manifested as poor performance and the intervention was perceived to be a punitive aspect of performance management. The hostile attitude toward inter­ventions is exacerbated by mandates for attendance by some organizations at physician health programs as a condition for future practice. The evidence, however, is that attendance at such programs can be beneficial and can facilitate reengagement of health care providers in their previous activities and reestablish mental balance.

Numerous tools have been used to identify burnout, ranging from the Maslach Burnout Inventory¹⁵ to a Well-Being Index,¹⁶ as well as a further modification of this for physicians.¹⁷ Although some of these screening tools have shortcomings and versions of these can result in an overestimation of burnout,¹⁸ these tools have been useful to identify the prevalence in targeted groups.¹⁹ In surgeons, burnout rates range between 3% and 34% according to specialty.²⁰ For nurses, 35.3% showed symptoms of burnout, which correlated with episodes of absenteeism and poor performance at work.¹¹ Of interest, 44% of anesthesiology residents were at high risk of depression or burnout. This high-risk group demonstrated a larger number of medication errors compared with the low-risk group (33% vs 0.7%). This emphasizes the risks that provider burnout poses to patient safety and care.⁵

Surveys have been used as markers of stress and well-being, but these can also be used to assess the effect of interventions, as well as to see if there are any other associations to explain reasons that certain providers had a score indicative of burnout. These survey tools can highlight the importance of personal health habits²¹ and wellness practices.¹⁴ Interestingly, the identification with medicine as a calling can be protective element against physician burnout.²²

Posttraumatic stress disorder may occur in health care workers if they are exposed to a stressful event or situation of an exceptionally threatening or catastrophic nature.²³ An increased point prevalence was found in emergency physicians of 15.8%²⁴ compared with national prevalence for the US public of 3.8%.²⁵ Posttraumatic stress disorder was identified in 22% of surgical residents, and a further 35% were deemed at risk.²⁶ The most common stressors were bullying and an increase in the number of hours worked per week. Compared with other specialties in medicine such as anesthesiology, there was no statistical difference in the prevalence of PTSD among surgical residents, yet 8 independent risk factors for the development of PTSD were identified, including higher postgraduate year, female gender, public embarrassment, emotional exhaustion, feeling unhealthy, job dissatisfaction, hostile hospital culture, and increased patient load.²¹

Physicians have a greater risk of depression compared with the general population. It is unclear whether burnout is a distinct phenomenon or a type of depression. One study by Wurm and colleagues used a questionnaire of 6351 Austrian physicians that incorporated the Major Depression Inventory and the Hamburg Burnout Inventory.²⁷ They reported that 10.3% of the surveyed physicians were affected by major depression, and 50.7% were affected by symptoms of burnout. A systematic review of depression and depressive symptoms found a summary estimate of the prevalence as 28.8% among resident physicians (range, 20.9%-43.2%).²⁸

What is clear is that the treatment of depression mandates a shift in professional and institutional attitudes to support physicians seeking help.²⁹

A systematic review and meta-analysis demonst­rated that physicians are at high risk of suicide with an overall standardized mortality rate of 1.44 (95% CI, 1.16-1.72). Both male and female professionals were at increased risk compared with the general population, but comparatively, female physicians were at greater risk than their male counterparts. Some countries had a higher suicide risk than others (US vs rest of world). Furthermore, there was increased stress among anesthesiologists and other specialties dealing with life-threatening emergencies.³⁰ To compare suicide rates in doctors with other professions, Agerbo and colleagues studied 3195 suicides and 63?900 matched controls. The risk of suicide among doctors was 2.73 (95% CI, 1.77-4.22) compared with primary school teachers, whereas architects and engineers had a lower comparative risk of 0.44 (95% CI, 0.27-0.72). There was little occupational association with suicide among people with psychiatric illnesses, except for doctors, for whom the excess risk was 3.62.³¹

Alcohol abuse or dependence is a significant problem among physicians.^2,32 Anesthesiologists are at higher risk of substance use disorder by 3-fold compared with other specialties. The self-reported incidence was 1.6% for residents compared with 0.3% for clinical fellows.³³ This was comparable with another US survey over a 7-year period.³⁴ The main factors are unclear, whether there is inadvertent sensitization by occupational exposure, ease of access to the medication, or a manifestation of the underlying stressors in their professional role.

Transplantation as a specialty has many underlying stressors that can precipitate adverse mental health, including long working hours, overnight duties (eg, the transplant surgery), long duration of training, an unhealthy work-life balance, and high-risk patient population with the propensity for major morbidity and mortality.

A national US survey of transplant surgeons from 2015 demonstrated evidence of burnout: 40.1% scored high on the emotional exhaustion dimension, 17.1% demonstrated high levels of depersonalization, and a further 46.5% had low levels of personal accomplishment.³⁵ In Europe, the evidence of emo­tional exhaustion was lower (17.6%), deper­sonalization was similar (26.9%), and personal accomplishment was lower (26.9%).³⁶ For transplant nurses, a study by Jesse and colleagues in 2015 demonstrated high levels of emotional exhaustion (50%), 15.7% reported high levels of depersonalization, and 51.8% reported low levels of personal accomplishment.³⁷

Liver and kidney transplant nurse coordinators demonstrated an average level of compassion fatigue and burnout compared with other nurses, but this was dependent on their education levels.³⁸

Organ donation is emotionally challenging, whether it is from a deceased or living donor. Deceased donation is inherently dependent on someone’s death, which may sometimes be caused by very traumatic circumstances, often causing an emotional impact on those providing donor care.^39,40 Normalization of the organ retrieval process and the emotional detachment necessary to perform under such circumstances can lead to compassion fatigue in transplant coordinators.^38,41 Another complex aspect of deceased donation is the ethical challenges of donation after brain death as well as cardiac death. The technical aspects of multiorgan retrieval can be detrimental. For example, operating on a patient who has a beating heart and then deliberately cross-clamping the aorta while the heart is beating and then routinely allowing the patient to exsanguinate can have an adverse mental impact on the health care team within theater.⁴² Donation after cardiac death poses a different challenge, as there is the need for the certification of death as well as the added stress of safe procurement of the organs in a timely manner to minimize ischemic damage. This can cause stress to health care workers who may be unfamiliar with the circumstances and who may need education regarding the process to understand the purpose of what may otherwise appear barbaric. If any technical issues arise, then the individual may self-blame or blame others in the team, which may escalate to widespread duress with a devastating impact, especially if there is a suboptimal outcome in the recipient.

Living donation also presents a unique challenge when the healthy donor is put at risk with no physical benefit to oneself and if there is a perception that such procedures compromise the Hippocratic oath. The chances of death after a kidney donation can be high as 1 in 3000⁴³; for liver donation, this chance may range from 0.1% to 0.5%, but there is also the risk of significant comorbidity associated with donation.⁴⁴ The adverse outcomes in either the donor or the recipient following living donation presents a major psychological challenge to the health care team, as the potential outcome could result in death in both the donor and the recipient with an effective 200% mortality. This stress is further exacerbated in countries in which living donation programs are still under development. During earlier experience, a highly publicized death led to the suspension of a transplant program and reduced enthusiasm for living donor liver transplantation nationwide. Eventually, the root cause analysis of early experiences and the establishment of protocols specific to living donations have allowed the growth of the living liver donation program in the United States and ability to overcome the deceased donor shortage and cautiously explore the role of liver transplantation outside of standard criteria.⁴⁵ It remains clear, however, that the ramifications of donor death are wide-reaching and remain a potential source of stress for all involved.

The scarcity of organs is a remarkable source of stress for the entire health care team while they are caring for patients with end-stage liver disease whose short-term transplant-free survival rate is very poor. Conversely, the responsibility of ensuring that those resources are used appropriately to bring maximum benefit to the national pool of waiting recipients while also advocating for their own patients is a significant challenge. If a perioperative death were to occur, this would be a tragedy not only for the deceased recipient but also for another potential candidate recipient who could have received the organ if a different decision or circumstance were at hand.

All complications can have an adverse impact on health care professionals. It is known that these complications can contribute to stress, resulting in and impaired performance. The quality improvement process includes understanding the nature of the complications and identifying processes to avoid future adverse events. Inadvertently, the root cause analysis puts individual health care providers into the spotlight. Regrettably, scrutiny of every decision that has been made may apportion blame rather than focus on education and prevention of future mistakes. The forensic investigation can have a devastating impact on individuals, especially if there are accusations of malpractice.

Donor transmission of infection or malignancy can be calamitous to the recipient. Although there are guidelines to support these decisions, the limited donor history and circumstances around donor death may compromise the ability to make a fully informed judgment. Worldwide, there have been high-profile cases of donor-derived malignancy and infection transmissions that resulted in adverse publicity for individual health care providers as well as entire transplant centers. The psychological effects of such adverse outcomes, often enhanced by malpractice suits, are devastating for transplant providers whose ultimate goal is to save patients’ lives.

On March 9, 2019, the World Health Organization declared a pandemic of COVID-19, and this has threatened the success and sustainability of transplantation worldwide and increased the pressure on the health care workforce.^46-48 At the time of writing the uncertainty about the nature of this disease in transplantation is confounded by the limited ability to screen donors and recipients, the poor sensitivity of the tests, the current lack of access to antibody-based testing to confirm previous disease or immunity, and the lack of vaccination for COVID-19.

These uncertainties add to pressure on transplant teams and psychological stress on individual providers.^49,50 This of course will change as more experience and understanding is accrued with the disease, and the current need for center-based practices will be replaced by newly developed consensus statements.

Moreover, providers may have their own health issues that increase their vulnerability to severe infection with SARS-CoV-2 or have vulnerable family members at risk of the infection. Balancing their professional responsibilities and stressors with their individual and family health needs deserve recognition and respect.

It is clear that the COVID-19 pandemic has created a confusing and rapidly evolving situation that is placing patients and frontline health care workers in a vulnerable state. This has further highlighted gaps in mental health support for clinicians,^51,52 and tailored psychological interventions are essential to maintain the health of the workforce at a time of prolonged risk and uncertainty. In many ways, it is also a watershed moment and an opportunity to address previously identified psychological needs, as described above.⁵³ There is evidence of, and high potential for, moral injury defined as the distress and functional impairment that occurs to an individual when exposed to a traumatic event that violates their moral values.⁵⁴ During the pandemic, there is a potential betrayal of what is right, either by the self or by someone in legitimate authority in a high-stakes situation, for example, the decision to maintain or to cease life support in the face of scarce resources.⁵⁵

Although the pandemic represents a unique situation with need for emergency planning, it also exposes and exacerbates a silent disaster of failed attempts to help transplant professionals to combat their own psychological injury. This calls for proactive dialogue between transplant professionals and their health care systems and aggressive allocation of resources to identify and manage provider burnout. The cost of burnout has many consequences including the attrition of the workforce by early retirement, reduced clinical hours, and loss to the profession by suicide, as well as compromise of patient safety.^56,57 The impact of malpractice cases on the organization and damage to the reputation should not be overlooked, regardless of whether it is a cause or consequence of burnout.^58,59

The organizational strategic focus should move from placing resources on supporting staff once they have developed burnout and mental illness to preventative strategies by the promotion of well-being.⁶⁰ Organizations should immediately reflect on the working conditions such as shift working, night shifts, workload, staff-to-patient ratio, reduction in nonclinical duties by addition of administrative staff and clinical support staff. The job opportunities should be optimized, and staff should be adequately remunerated with a degree of autonomy, although this of course is a challenge for any health service. A study of lifestyle characteristics among US abdominal transplant surgeons emphasized a significant amount of time that was spent on nonsurgical patient care, research, education, and administration, with over 70 hours of work per week and only 195 operative cases per year.³⁵ A German study of abdominal transplant surgeons from 2015 demonstrated a perception that salaries were inappropriately low and career prospects were inadequate.⁶¹ The usability of electronic health records has also been shown to be a source of stress and subsequent burnout,^62,63 and this could be mitigated by the use of scribes or medical assistants in the team.⁶⁴

The provision of psychological support should be made readily available with drop-in sessions within comfortable surroundings⁶⁵ and provision of mindfulness programs^66,67 and remote digital learning packages,⁶⁸ especially if there is an added stress of traveling to and from the hospital.

Peer support should be encouraged, although it is recognized that offloading to a stranger can be useful in order to acknowledge feelings they are struggling with, including fear, anger, and a reluctance to come to work at all.

The real benefits of good peer support are to identify signs of burnout among the providers, offer providers the ability to talk, direct them to resources, encourage them to maintain good self-care, and help them to explore the causes of their distress. Regular peer support ensures that clinicians have a sense of each other’s “baseline” and are more likely to notice earlier if there are changes in a colleague’s behavior, performance, attendance, or emotional state.

Small group discussions have been identified as useful as it consolidates team performance and ensures that people can feel valued. A regular monthly facilitated safe reflective space meeting (a Schwartz round) has been shown to increase self-compassion and reduce feelings of isolation and stress.⁶⁹ This intervention has the advantage of being proactive. In addition, psychological first aid for emergency service workers has been successful and could be applied widely in health care.⁷⁰

Health care workers within transplantation are exposed to the risk of burnout, which is comparable with or potentially even higher than that shown in other health care professionals. Yet, the transplant community has not developed consistent, proactive methods to address this risk. The COVID-19 pandemic has, however, reemphasized mental health issues for all areas of the health care workforce. Now is the time to work with earnest enthusiasm as a health care community (ie, providers and organizations) to address this critical issue and attain the expected benefits to providers, to promote their well-being and increase their capacity to withstand the predictable strain experienced at work.^71,72 This will also benefit the culture of our health care organizations but ultimately and importantly will positively affect patient care.⁷³

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