‘Zugzwang. It’s when you have no good moves. But you still have to move’ Michael Chabon¹

Introduction

Today, many clinicians are not just working hard. They are working in conditions where the right thing to do may be clear, but the system makes it difficult, and sometimes impossible. Decision making becomes increasingly exhausting; the need to focus on self-care becomes increasingly difficult as clinicians attempt to compensate for system problems on a daily basis.

This is the breeding ground for moral distress, burnout and poor patient safety. 

Moral distress is the pain of being unable to do what one believes is right. In healthcare, that pain is often structural: clinicians know the care a patient needs, but lack the time, staff, beds or systems to provide it. When repeated and unresolved, this can deepen into moral injury, with guilt, shame, anger, alienation and lasting psychological harm².

Burnout is different, though closely related. Burnout is the depletion that follows sustained overload, low control and insufficient support. It is characterised by exhaustion, detachment and a loss of meaning or effectiveness³. In healthcare, moral distress and burnout often become mutually reinforcing. The more clinicians are prevented from working in line with their values, the more emotionally exhausted they become. The more exhausted they become, the harder it is to carry further moral strain. This is what Christina Maslach has called “a slow erosion of the soul’⁴.

The traditional professional ethic in healthcare is clear. We are taught, rightly, that patients come first. The General Medical Council states that doctors “must make the care of patients your first concern” ⁵, while the Nursing and Midwifery Council says registrants ‘must make care and safety of people using their services their main concern’⁶. These principles are foundational. When demand rises, resources are constrained and workforce shortages persist, this professional ethic becomes hard to inhabit and can become exploited by the system. Clinicians give more of themselves because they know patients will suffer if they do not. There is no ’off-switch’ as demands feel never ending.

The Clinical Zugzwang

In chess, zugzwang is a position in which every available move worsens the position, yet a move must still be made. For many clinicians, this now feels uncomfortably familiar.

One move is to keep giving: cover the extra shift, overbook the clinic, skip breaks, stay late and carry home the emotional residue of the day, too tired to recharge with friends, family or through recreation. In the short term, this may protect patients and colleagues from the sharpest edges of an inadequate system. But the cost is high. Energy drains away, relationships, interests and self care are neglected. The risk of burnout rises. Organisations pay too, through poorer retention, sick leave, lower productivity, disengagement and reduced patient safety. Too often, this creates a vicious cycle. Inadequate systems push staff to compensate for deficits through discretionary effort. Over time, staff become burnt-out, performance and capacity decline, and systems become even less safe. The cycle of moral distress and burnout then deepens further.

The other move is to protect oneself: decline the extra shift, hold clearer boundaries, and refuse to compensate for structural deficits, leave on time and have the energy to recharge. This is often the healthier and more sustainable response. It may even be the more professionally responsible one, maintaining longer term patient care and safety. However, such actions may create feelings of guilt, shame, or a sense of abandoning patients and colleagues and of not ‘putting patients first’. Self-preservation can therefore feel like betrayal, resulting in moral distress.

Under such stressful conditions, we often choose avoidance of short-term discomfort over longer term sustainability, avoiding the moral distress.  

Neither move feels good. Yet a move still has to be made. That is the clinical zugzwang.

Conclusion

A system that repeatedly places good, dedicated staff in positions where both self-sacrifice or self-protection feel morally compromising is not simply under pressure. It is ethically corrosive. Safe care, and high-quality patient care, depends on conditions that do not routinely force clinicians into such trade-offs. Data from the NHS staff survey consistently highlights that further work is needed to improve the working environment and experience for NHS staff⁷.

If we are serious about patient safety, we must be serious about the conditions in which care is delivered. That means recognising the hidden reliance on discretionary effort and refusing to romanticise sacrifice as professionalism and busyness as a badge of honour. It means understanding that staff wellbeing and patient safety are not competing priorities but are deeply interdependent.

If a move has to be made but neither choice feels good, is there a third option?

Moving healthcare out of this clinical zugzwang by redesigning systems in which staff can work sustainably, feel valued, and thrive might be that preferred move – removing the clinical zugzwang described above. Thriving staff have greater capacity to think, relate, innovate and improve care. This is a condition of quality and safety and long-term sustainability of healthcare.

Your move…

References

1.  https://quotefancy.com/michael-chabon-quotes
2. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic BMJ 2020; 368 :m1211 doi:10.1136/bmj.m1211
3. Duggins R. Burnout-Free Working. 2025. Jessica Kingsley Publishers 
4. Maslach, Christina, and Michael P. Leiter. 2000. The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It. John Wiley & Sons.
5. General Medical Council, Good Medical Practice 2024
6. Nursing and Midwifery Council, The Code Professional standards of practice and behaviour for nurses, midwives and nursing associates 2018
7. NHS England. National results briefing 2025: NHS Staff Survey. [Online]. Available at: https://www.nhsstaffsurveys.com/results/national-results/ (Accessed: 10 April 2026).

Authors

Dr Mick Button is a Consultant Oncologist and Associate Medical Director (workforce)

Dr Anna Baverstock is a Consultant Paediatrician and Associate Medical Director for Senior Doctor Wellbeing/Leadership

Dr Paul Molyneux is a Consultant Neurologist and Coach

Dr Richard Duggins is a Consultant Psychiatrist and Associate Medical Director for Medical Development, Leadership and Culture

Declarations of Interest

Mick Button: None

Anna Baverstock: Senior consultant at Doctors Training, speaker with Civility Saves Lives

Paul Molyneux: Senior Facilitator at Doctors Training and Director for The Thriving Life Consultancy

Richard Duggins: Has received fees for training on wellbeing and burnout