By Fiona Wallace, director, FW Clinical Research Ltd.
This article is the third in a four-part series that investigates the disillusionment clinical research associates (CRAs) feel with their role today, why they feel that way, and what we can do about it. The series is based on a survey I conducted of almost 800 CRAs and line managers (LMs). Part 1 explained my reasons for conducting this research, and Part 2 looked at what CRAs said about burnout and their mental health. This part will explore the survey responses provided by the LMs themselves, as well as the CRAs’ responses concerning their LMs and the companies for which they work.
Each of the five sections that follow presents a question from the survey, followed by an overview of the responses to that question, my analysis of those responses (where applicable), and any standout comments from participants.
LMs: Would you know what to say or do if your team member confided they were struggling with their mental health?
I wanted to get some perspective from respondents who were currently line-managing CRAs. Of the 280 who answered, it was almost an equal split between LMs who felt they would know what to say or do if a team member confided about their mental health and those who did not.
Looking at the additional free-text “Other” answers, there were a lot of N/As, as the majority of respondents were CRAs. However there were some interesting comments from current LMs:
- They wouldn’t know what to say and would be nervous about making the situation worse. However, they really want to support their reports; they just do not know how.
- They felt there was not enough guidance on how to have a conversation about mental health.
- Some LMs who had a medical background said they have had these conversations with their team members, but they only knew what to say due to their medical background and previous training.
- They want to encourage their teams to reach out but are fearful of going into too much detail, due to feeling unprepared.
- Some felt it was very dependent on the employer’s culture as to how such communications would be managed.
Practical examples of how LMs had managed discussions about mental health with their teams were:
- providing information to their team member (signposting)
- encouraging them to seek medical help
- exploring the use of any PTO (paid time off) that could be taken
- investigating any controllable work adjustments that could be made
- seeking guidance from HR.
LMs: What could support you in being able to discuss mental health with a member of your team?
Nearly 200 LMs responded to this free-text question. I grouped their comments by topic and ranked them by number of responses (most to least):
- Training in any format, e.g., online, instructor-led, webinar (33 responses) — Examples included company-wide mental health awareness days, half-day workshops, annual mental health training sessions, how to spot the signs of CRA burnout, how to prevent it, and the best language to use.
- Mental health policy/HR support (27 responses) — Having a mental health policy in place either as a stand-alone policy or incorporated into a general health and safety policy. The policy could outline available resources and options (PTO, employee assistance program [EAP)], working from home, one-on-one discussions), providing guidance to both LMs and employees.
- Resources available (17 responses) — Being able to signpost the resources available to the CRA, such as EAPs, online mental health toolkits, and anything else that gives guidance to both the LM and the employee.
- Building trust (15 responses) — LMs felt their reports were not able to connect with them, and a more open culture regarding mental health in the organization would improve the trust between the LM and report.
- Culture of support from senior management (11 responses) — It was felt if an organization adopted an open, non-judgmental approach to mental health in the workplace, this would improve trust, which would then improve communication and lead to positive improvements for both the employee and the company.
- Resource (11 responses) — Resources were too scarce, resulting in no time allocated for one-on-one discussions due to workloads not being manageable (for both CRAs and LMs).
- Don’t know (six responses) — They wanted to help but did not know how.
- Nothing, as they were fine and could handle the situation (six responses) — Note that three of these attributed this to their medical background.
- No (four responses) — It was felt the mental health of an employee should absolutely not be discussed, it is far too personal, the LM is not their psychiatrist, and perhaps they should find another industry better suited for the CRA to work in.
I felt positive after reading the survey responses to this question, as they show the CRAs and LMs have some great ideas on what can be done to improve their working environment and CRA-manager relationship.
Summarizing the survey responses for what would help LMs, the top three are access to mental health awareness training, having a mental health policy in place, and being able to signpost resources. From my own perspective in the U.K., this is beginning to happen, with many major companies coming together to share experiences and make such tools available.
I do think the last comment is important, as LMs should not act as therapists or psychiatrists but more as a non-judgmental person whom their report feels they can communicate with, who is then empowered to help the CRA by listening to them, directing them to appropriate resources, and feeling comfortable with the conversation.
CRAs: Is there anything your current employer does (or a previous employer did) well to maintain mental health of their employees?
The top three answers were flexible working hours, a good LM, and the benefits package.
Within the free-text comments, the most common response was that a CRA’s employer may have a great package; however, the CRA was either too busy to use features of the package (working 70-/80-hour+ weeks) or they are out of the office for the majority of time and cannot access these benefits. Another common response was that many are field-based or work remotely, so they also do not have access to some of the office-based benefits.
The survey respondents provided some additional ideas that may improve mental health and well-being:
- Opportunities to work part-time
- Regular email tips with ideas and prompts on how to manage your self-care
- Companies scheduling a half-day workshop on mental and physical well-being, incorporating relevant skills building
- Option of unpaid leave and flexibility when to take it
Airline comfort club memberships
- Access to a willing mentor (someone experienced who can act as a sounding board)
- Options to take a sabbatical at a specified number of years worked, e.g., two months every two years.
- Being able to take time in lieu, i.e., paid time off work for having worked additional hours
- Company excursions/trips/team building
- Access to 24-hour counseling helplines (this does come with some EAP packages)
- One personal day per quarter
“I am currently freelancing as a CRA, and this is the only way I can do this job. Money is good, and you are only contracted for a certain amount of time. I can see an end to the job and then move on to the next project.”
This comment concerned me as it implied some employees feel they need to become freelancers, as their workloads are so intense that they can only be managed in short bursts at a time.
“Employer constantly tries new ideas to promote work/life balance for all employees and is very open to employee suggestions about things to try.”
“My employer offers only one of the above. Do other employers really provide these benefits???!”
“Can't really benefit from flexible hours because you're working 10+ hours a day.”
I also believe companies have an obligation to check that the benefits packages they offer are realistically accessible for their employees and, if they are not, explore root causes of why.
CRAs: Would you ever choose to work for an organization that paid you a lower salary (i.e., less money/benefits than a competitor would offer) but had a proven track record of good mental health awareness and support within the workplace?
I realize this hypothetical question was quite subjective and in reality there are many more variables than salary and mental health awareness when considering a CRA role. However, I was surprised at how low the percentage was for those who would work for the organization that paid the most money. Good salary and benefits packages have always been the main tool for attracting employees; however, I think CRAs are beginning to consider the bigger picture about how the role and type of employer will affect their life/work balance. HR and recruiters, take note.
I grouped the free-text comments by topic and ranked them by number of responses (most to least):
- Twenty-eight stated that as CRAs they have made the decision to move to another company with less hours traveling and a more regular week (40 hours). They have taken less money to do so. Seven of these 28 respondents are currently in the process of doing this. One respondent added they took a 20,000 pay cut and are much happier.
- Thirteen replied they would not consider a role with less pay (even if there were added mental health awareness benefits) because they saw the higher pay as direct compensation for how stressful and exhaustive the CRA role is. Also, there were those who cannot afford to take a pay cut due to their financial circumstances, e.g., paying off student loans, being the main earner in the family household, living in an expensive state (U.S. respondent).
- Twelve commented that companies say the right things to entice you to work for them, but once you work there, you realize these claims were untrue, e.g., an organization may say you will have a manageable workload within 40 hours a week, less days on site, etc., but this proves to not be true. This fosters a level of distrust between CRAs and employers.
- Eleven respondents found this question difficult to answer; they wanted to know all the details first. This does not surprise me. It is their job to gather and assess details!
- Six comments were about wanting to do a good, high-quality job rather than rushing all their tasks, asking why couldn’t there be both elements, i.e., supportive mental health awareness and a competitive salary, and concerns about new management once they start a role in such a supportive company.
“In this industry, you learn really quickly if they dangle a ton of money your way, there’s a reason. Be prepared to work your butt off. Money isn’t everything.”
“Many organizations say the right things about taking care of their employees’ mental well-being and work/life balance, but after joining it is the opposite.”
“Again, actions or words? I would definitely take a cut in salary to work for a company that included me in resourcing decisions that made sense and truly provided work/life balance options and practices. Like matching sponsor assignments and CRAs, being realistic with travel expectations versus administrative task timelines, offering paid sabbaticals, or allowing CRAs to just periodically take a year with a desk position to get off the road and exhale. Most of us actually love some level of travel; we just need a break every so often when it gets to be too much. I would not take a pay cut to work for a company that trains LMs to listen empathetically but could not change anything.”
“All-in-all, not being paid isn’t acceptable. Our jobs are tough (hence this survey) and all companies talk about this stuff. No. One. Does. Things. Differently. when it comes to mental health or burnout. As an employee, you go where the money is because you know companies don’t care about you or your mental health. They want metrics. They want you traveling, period.”
“I already feel I could have made more money working elsewhere. However, this company starts you with three weeks of vacation, Christmas to New Years is a company holiday (so no need to use vacation), and we get one personal day per quarter. The access to vacation is extremely important to me so I can take regular breaks and not feel extremely limited. This was one of the main reasons I was very excited to join this company and one of the main reasons it would be extremely difficult for a competitor to entice me to leave.”
“Yes. I have accepted a new position at a lower salary for that reason.”
“Mental health is important, but it is also up to the employees to set boundaries and take vacations/mental health days when needed. Most people do not take proper care of themselves. Luckily I have an LM who constantly reminds us to take PTO.”
I noticed there is a strong sense of distrust again between what has been promised to CRAs and what eventually becomes the working reality. However, there was evidence that some organizations have made changes to their environment which have resulted in happier CRAs. On the whole, these tended to be smaller clinical research companies and/or LM-dependent.
Do you have any further comments regarding the questions in this survey or about how mental health affects your work/life balance?
Again, ranking and grouping common themes:
- Forty-two said they felt the role was becoming very stressful and the workload is far too high. Many comments cited 80-/90-hour weeks, lots of days on site, completing site reports in the evening and during family time — overall less time spent in the “life” part of “work/life balance.”
- Fifteen felt mutual recognition would be extremely beneficial to helping CRAs stay at a role, i.e., the company realizes the demands of the CRA role and supports this by their actions, such as offering flexible working hours and downtime after a period of travel. It was also felt that if an LM had not experienced the CRA role, this had a damaging effect on the CRA-LM relationship in terms of empathy.
- Seven added they felt it was more important that their health was prioritized over the demands of the role and credited their LMs with supporting them.
- Five respondents felt the survey did not ask the right questions. They wanted more specific questions on travel time and number of sites and felt the survey was misleading in that it focused on mental health not burnout.
- Four were thankful for the survey giving them the opportunity to freely discuss their mental health.
There were also comments mentioning stress will harm your career and may be used against you and that each CRA has a responsibility to take control of their own self-care.
“I think people really underestimate the power of human contact. For four months, I was on the road. No one ever talks about this, and as someone who is very aware of the many scopes of depression, this was a whole new thing.”
“Discussing stress impact leads to lower annual review grades; by the way, I am in the U.S.”
“I find it hard to discuss my mental health with most people, either outside my company ('You're young, don't have a house or kids, and you get to travel all over! How could you not like your job?' or 'This is the best time for you to do this! I wish my job paid for me to fly everywhere') or within it ('You signed up for this!' or 'Give it some more time; you'll get used to it!'). No one really understands what the job entails unless they're in it currently or within the last five years. Things change so rapidly in this industry, especially over the last decade, if management hasn't been in this role or were in it 10+ years ago, they do not understand the challenges we face. I do not want to disappoint my managers or family with my struggle with my mental health with this job. I am generally an optimistic and happy person, but sometime this job depresses me. Sorry for the long spiel here, but I needed to get it out to someone other than my family or closest friends.”
“Work/life balance is off. The effect of eight to 10 days on-site a month is significantly altered by the length of the visits, one day versus two or three days due to travel requirements, which is not taken into consideration for metrics. It’s exhausting if you have all one-day visits and then eight to 10 trip reports instead of five or six. Very anxiety-provoking.”
“The lifestyle of a CRA is horrendous for mental health. Too much travel. For me, I had to give up most of my regular sports when I was a CRA, combined with exhaustion, poor diet on the road, and complete lack of support at that time. I became suicidal. I will never ever go back to that job because it nearly killed me.” (NOTE: If you are feeling suicidal or know of someone who needs help, visit https://www.iasp.info/resources/Crisis_Centres/ to find a crisis center anywhere in the world.)
“I love my new manager, she tells me to never over-burn.”
“The level of stress is still increasing in the last two years in [CRO name deleted]. I´m afraid it could reach the level of other CROs and [CRO name deleted] will lose its good name relating to dealing with employees!”
“If you are aware abuse is taking place and listen compassionately, but allow the abuse to continue (or just suggest they get more exercise), it’s not very effective. You want mentally healthy and happy CRAs? Stop talking about it. #1: Empower them in decisions regarding how/to whom they are best resourced before assigning to projects (hire a project/CRA matchmaker). #2: Give them sabbaticals or optional rotation to desk-only assignments for weeks or months to recuperate from lengths of nonstop travel projects. CRAs will revive and look to jump back on the road at some point. #3: Pay senior CRAs a ‘stay-here’ bonus every couple of years, because the ones with experience can’t get decent raises unless they change employers. They feel unappreciated. It’s about stopping the mental health dilemma before it starts. Treat us like humans.”
There are some very strong views here. I see themes of overwork, distrust, and lack of communication. However, I also see some great ideas for how to address this.
Returning to the question posed in the title of this article — CRA Burnout: Are Employers (And Managers) Equipped To Address It? — I believe the answer is yes! There are things we can all do. Some organizations are doing this, and some are at different places than their counterparts.
There is no single magic bullet. There are many pieces to the whole jigsaw, which will be covered in the last installment in this series, Part 4, about how we can combat CRA burnout and foster improved CRA well-being.
In the meantime, please stay tuned and share your experiences and insights in the Comments section below.
About The Author:
Fiona Wallace, director at FW Clinical Research Ltd, has worked in global CRO and pharma for 18 years. Her experience spans many countries and continents including India, South Africa, the U.S., Europe, and Central and Eastern Europe in Phase 1 to 4 studies in oncology, ophthalmology, erectile dysfunction, and rheumatoid arthritis. She specializes in developing high-value staff retention and engagement solutions by utilizing her experiences in project and CRA management, global clinical regulatory training, and inspection-readiness management. Her latest project is to open up the discussion of mental health in the clinical research workplace, with the goal of improving the quality of life for everyone working in the spectrum of clinical research. Wallace can be reached at email@example.com.