Causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics: the Care Under Pressure 2 realist review

Project overall aim

To improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related psychological ill-health; and determine which high-quality interventions can be implemented to minimise psychological ill-health in nurses, midwives and paramedics.

Our specific aims are to

• A1. Understand when and why nurses, midwives, and paramedics develop psychological ill-health at work, and provide examples of where and how it is most experienced;

• A2. Identify which strategies/interventions to reduce psychological ill-health work best for these staff groups, find out how they work and in what circumstances these are most helpful;

• A3. Design and develop resources for NHS managers/leaders so that they can understand how work affects the psychological health of nurses, midwives and paramedics; and what they can do to improve their psychological health in the workplace.

Objectives

We will undertake a realist review to test and refine programme theories to meet A1 and A2 above to identify the following:

• O1. How and why work has a positive or negative effect on the psychological health of nurses, midwives and paramedics and in what contexts these are most experienced and have impacted;

• O2. The mechanisms at individual, group and professional levels by which strategies and interventions prevent or reduce the impact of work on the psychological ill-health of nurses, midwives and paramedics; and explain why, for whom and in which contexts these are most beneficial for these staff.

Using evidence from O1 to O2 above and informed by evidence-based implementation theory and stakeholder involvement we will

• O3. Develop a range of resources to support NHS managers/leaders to understand better how work affects the psychological health of nurses, midwives and paramedics and identify what they can do to improve their psychological wellness in the workplace.

Step 1a: locating existing theories

The goal of this step was to identify theories that explain how and why work has a positive or negative effect on the psychological health of nurses, midwives and paramedics and in what contexts these are most experienced and have impacted most significantly. Also, to identify the theories explaining how and why interventions prevent or reduce psychological ill-health in nurses, midwives and paramedics; and explain why, for whom and in which contexts these are most beneficial.

For interventions to be successful in moderating the impact of psychological ill-health it is necessary to understand the relationship between the development of psychological ill-health at work for nurses, midwives and paramedics (the [causal] underpinning theory or theories), so that the interventions can be selected that may ‘intervene’ and minimise psychological ill-health. In realist terms, these are the programmes. Programmes are ‘theories incarnate’ (not always explicit or visible) – that is, underpinning the design of programmes or interventions, and include assumptions about why certain components are required and how they might work. These theories are often implicit; the designers of interventions have put them together in a certain way based on what needs to be done to get one or more desired outcomes. The realist researcher aims to make these more explicit and visible where possible.

The team began by building on the CUP-117,43 final programme theory as the initial programme theory for this study, and then took a specialised, inductive approach to go beyond what was already known (reviews of individual interventions) and determine a path through the potentially vast literature (see below). We also wanted to learn from and draw upon the knowledge and expertise of our stakeholder group.

Thus, an initial theory sensitisation stage consisted of the following activities. Members of the CUP-2 team

1. examined the CMO configurations and theories generated by our co-applicants (KM, DC, SB) in CUP-1. 17 Members of that project team (KM (principal investigator [PI] of CUP-1), DC and SB) are also co-investigators in CUP-2. When drawing on their findings in early discussions we identified some of the similarities and differences across professions. These led to the identification, extraction and comparison of nationally available data for demographics, service architecture (ways of working) and well-being outcomes for doctors, nurses, midwives and paramedics to underpin this work,4 see Step 1b below;

2. drew upon PI (JM) previous HS&DR funded study exploring patients’ experiences of care and the influence of staff motivation, affect and well-being (HS&DR-08/1819/213) and extended our understanding of psychological ill-health at work and the impact of staff psychological ill-health on patient care;

3. drew on PI’s (JM/CT) realist expertise from their previous HS&DR funded longitudinal evaluation of Schwartz Center Rounds as an intervention for enhancing compassion in relationships between staff and patients (HS&DR-13/07/49) – considering its findings in the context of other interventions for the improvement of psychological ill-health in nurses, midwives and paramedics;

4. consulted with experts representing multidisciplinary perspectives in our Stakeholder group (including our nurses, midwives, paramedics and patient and public involvement and engagement [PPIE] representatives);

5. considered findings from NIHR HTA project – facilitating return to work of NHS staff with common mental health disorders: a feasibility study (HTA-15/107/02) about the role of OH in supporting staff with psychological ill-health;

6. drew on key reports published by advisory and steering group members: Michael West’s King’s Fund report30 and Gail Kinman and Kevin Teoh Society of Occupational Medicine (SOM) report25; along with additional informal searching to identify causal explanations about how the programmes’ impact on staff mental health/well-being. Contextual factors (at different levels, for example, individual, organisational, economic, social) related to risk of psychological ill-health were extracted and synthesised, and preliminary CMOcs developed (see Appendix 2, Table 14 for an example).

This early activity allowed the team to explore the possible theoretical underpinnings, including structural features of work (which we called ‘service architecture’), on which programmes are based, in order to map out the conceptual and theoretical landscape of psychological ill-health causes and intervention outcomes and how they are supposed to work, for nurses, midwives and paramedics. This informal searching differs from the more formal searching process in Steps 1b and 2 in that it is more exploratory and aimed at quickly identifying the range of possible explanatory theories that may be relevant.

Step 1b: understanding key contextual features that may impact on psychological ill-health

The research team brainstormed key contextual features (important contributors to psychological ill-health for nurses, midwives and paramedics) and compared these to each other and to doctors, based on our own expertise and knowledge. We shared drafts of these demographic, service architecture and well-being features with our stakeholder group on two occasions requesting comments on their importance and to identify any omissions. Feedback suggested that the features we identified provided a useful summary of key statistics that could inform attempts to improve workforce well-being.

To understand the service architecture better, we next searched for whole NHS workforce data (focusing on hospital and community health services staff) where possible using NHS Digital NHS workforce statistics) and/or NHS England-related sources based on the whole NHS hospital or community services workforce in England. We prioritised the sources where data could be separated by the three professions of interest and compared with doctors. This was important because our review builds on CUP-1,17 which focused on doctors. We found limited data for the primary care workforce, so focused only on hospital and community health service settings in England. Sources were rated for their strength/accuracy of evidence, and comparability across professions and a summary of the key demographic, service architecture (structural features of work) and well-being indicators were produced. 4 See Chapter 4 and Report Supplementary Material 1 for full publication.

Step 2: searching for evidence

This step involved searching bibliographic databases, supplementary searching in profession-specific United Kingdom (UK) journals and input from stakeholder and team member experts.

Initial database searching

The CUP-2 database searches were managed and executed by our information specialist (SB). Three rounds of searching were conducted during the review. This included (1) a search across all three professions; (2) an expanded paramedic search due to a dearth in the initial search of all professions; and (3) a COVID-19-specific search. CUP-2 was funded pre-pandemic and so the additional contextual factors caused by the pandemic in relation to causes and interventions were not considered within our protocol. While we recognised the limitations of focusing ‘only’ on the COVID-19 literature (e.g. in terms of extraordinary contexts, and poor quality of evidence) we felt it important to include this literature as an additional component. The methods are therefore explained in this chapter, but findings presented in the Appendices (see Appendix 3, Box 3).

The search terms and method for searches (2) and (3) are described later (see Second round of database searching and selection: literature reviews and COVID-19).

For search (1), across all professions, initial search terms describing psychological ill-health and outcomes of psychological ill-health were taken from CUP-1. 17,43 Additional search terms were added to retrieve papers relevant to nursing, midwifery and paramedic practice. Three databases were searched: Medical Literature Analysis and Retrieval System Online Database (MEDLINE) ALL (via Ovid, which includes MEDLINE In-Process), Cumulative Index to Nursing and Allied Health Literature database (CINAHL) (via EBSCO) and Health Management Information Consortium Database (HMIC) (via Ovid). These three databases were selected because they covered the core health science literature (MEDLINE ALL), nursing and allied health professional literature (CINAHL) and grey literature (HMIC). The search strategies included terms for the populations of interest (nurses, midwives and paramedics), common psychological ill-health problems (e.g. stress, anxiety, depression) and outcomes of psychological ill-health (e.g. sick leave and burnout). Anticipating a large volume of returns (especially in nursing) and to maintain the study’s relevance to the UK’s NHS context, we limited our initial search to UK-based literature. To accomplish this, a published UK geographic search filter was added to the MEDLINE search. 49 CINAHL did not have a UK filter option; however, a function within the database was used to limit studies to the UK geographic region. This is accessed via the Refine Results menu on the left-hand panel within CINAHL, under the subheading ‘Geography’, and allows the searcher to limit results to studies pertaining to pre-specified geographic regions, including ‘UK and Ireland’. The HMIC database, which is published by the UK Department of Health, the Nuffield Institute for Health (Leeds) and the King’s Fund Library50 has a mainly UK focus. With filters applied where they could be, three searches were conducted for each profession, and these were exported to Endnote X9 reference management libraries for screening. No date limits were applied to searches. The exclusion criteria we applied to literature captured in this initial search are presented in Table 3.

The initial searches were run in MEDLINE and CINAHL on 12 February 2021 and in HMIC on 26 February 2021. Appendix 4 describes the search process and results in detail (see also Appendix 4, Tables 17–20).

After screening, the initial database search for paramedic papers yielded a dearth of studies (n = 7). For this reason we ran an additional search with more sensitive search terms, informed by paramedic stakeholders and research experts and a published search filter for the paramedic field. 51 The revised search included a wider selection of medical subject heading (MeSH) terms and free-text terminology than the initial search, including terms such as ‘first responder’ and ‘emergency personnel’. Using these modifications, the second search for paramedic literature was undertaken in all three databases on 31 March 2021. Results from those searches are presented in Appendix 4, Tables 17–20.

Titles and abstracts for the total number of papers retrieved through the database searches were as follows: 1304 for nursing, 88 for midwifery and 79 for paramedics. These were exported to word files and filtered through a screening and selection process described in Step 3.

Literature reviews

Thirty of the most recent literature reviews identified (but set aside) in the initial database searches were included in this second round. Team members (CT) and (JM) independently reviewed titles and abstracts of each review and rated their inclusion based on a judgement of relevance to contribute to the emergent programme theory, and based on their knowledge of the literature and the potential for additional insights. Given the rich data found in the initial sample of papers, an additional 30 literature reviews were considered adequate to supplement the existing dataset (particularly as some key reports also contained recent systematic reviews or summaries of such reviews). The number of literature reviews in the quota was deliberately small, because secondary analysis in the included literature reviews contained fewer rich insights (thin data) for realist analysis in contrast to data found in the included primary literature, and most of the literature reviews were international (some not including any UK primary evidence), perhaps impacting relevance.

COVID-19

A second round of database searching was conducted on 7 December 2021, to supplement the ongoing work in building the synthesis with papers focused on COVID-19 and psychological ill-health in nurses, midwives and paramedics. The initial screening and selection of ~90 papers excluded papers on COVID-19 because we anticipated that the number of COVID-19 papers in the last 2 years might have ‘overwhelmed’ the RCQ screening, particularly in nursing. We also anticipated that COVID-19 papers might not contain the range or depth of service architecture insights related to the causes and solutions to workplace psychological ill-health, which have been in existence for many years prior to the pandemic.

Once a first draft of the analysis of the initial sample of included papers was complete (see below), the information specialist (SB) ran a second search for COVID-19 papers across three databases (MEDLINE ALL, CINAHL and HMIC), separately for the three professions. This search used the same professional and psychological ill-health terminology as the initial search, but replaced search terms for the outcomes of psychological ill-health with COVID-19 search terms developed by the UK Health Security Agency library services team (https://ukhsalibrary.koha-ptfs.co.uk/coronavirusinformation/). We applied a UK filter to the MEDLINE search but not to the CINAHL search, in view of shortcomings identified in the initial searches (see above, where some UK papers were missed by the CINAHL UK filter); however, we did prioritise inclusion of papers from the UK through the ranking system used for selection (explained below).

COVID-19 two-step identification stage inclusion/exclusion criteria

The exclusion criteria for the COVID-19 papers are presented in Table 4. The COVID papers were appraised differently given the aim to draw out COVID-19-specific causes rather than just exacerbation of known existing causes; and/or novel interventions and innovations. The search strategies used for each database are presented in Appendix 4.

The search for COVID-19 papers involved a two-step process. The initial step searched the 50 most recent COVID-19 papers in each of the professions to capture relevant information on the impact of the pandemic on psychological ill-health. The second step was a ranking process to select the top 10 papers in each of the professions for a total of 30 papers. As we anticipated, many COVID-19 papers reported only the acute negative state of psychological ill-health descriptively, rather than insight into the solutions developed in the context of the pandemic. The two-step selection process is described in Table 4.

Step 3: assessing papers for inclusion

As outlined above (and shown in Appendix 4), the database searches yielded a large literature for nursing and a smaller pool in midwifery and paramedic literatures. RCQ screening was applied to the sample, which meant that the most recent literature was prioritised over older literature.

Two members of the team (JJ) and (CT) used Excel spreadsheets to record their independent judgments about the inclusion/exclusion of all papers/articles and these decisions were compared. In almost all cases, discrepancies between JJ and CT were easily resolved; on three occasions, a third team member (JM) arbitrated on final inclusion. Appendix 5 provides a sample of the Excel sheet used with the inter-rater scoring process exemplified.

Step 4: extracting and organising data

Realist appraisal and appraisal journaling

An initial analysis, including CMO configurations, was drafted from a subsample of retained papers (n = 49) and reviewed by all team members. Papers were folded into the analysis in stages. All papers were read, and details entered into an appraisal journal (see below) by the team. On occasion, a paper was eliminated (or moved to a different part of the project, e.g. literature reviews or COVID-19) after reading the full-text, due to not meeting inclusion criteria that were applied at screening. This occurred when we screened papers without abstracts and had to read the full-text paper to know whether the paper met our inclusion criteria.

Realist synthesis appraisal involves an assessment of relevance and rigour of included evidence in the synthesis. 37 Pawson suggests that relevance in realist appraisal means adjudicating content of articles to determine how and in what ways they are relevant to the research questions and theoretical framing of the inquiry. An included primary study in a realist synthesis need not be appraised in its entirety, but rather the specific parts of the paper should be subject to scrutiny. 37 Therefore, we searched articles for causal insights that could be retrieved anywhere in the publication. These insights were extracted to the appraisal journal and reviewed by the whole team. Appraisal journaling was introduced to the team by coauthor (JJ) for this study as a step to be conducted before the full analysis involving CMOcs. A general process for the appraisal journaling included the following steps:

1. the full paper was first read and annotated

2. a new MS Word document was created for the journaling exercise. Title and abstracts for papers were imported into that document

3. using a free-write approach, one member summarised any important insights from the paper along with additional thoughts in a reflexive manner after reading the full text

4. the wider team then added their own free-thinking insights, expertise and NHS experience, providing challenge and counterarguments. This second-layer ‘journaling-on-journaling’ became an ongoing written dialogue amongst team members and served to build the analytic process, including notes to link theory and ideas from papers. An example of a journal entry is found in Appendix 6

5. subsequently, parts of the journaling were progressed to an analysis document, including key direct quotes from papers, and from there, CMO configurations were drafted. Links across papers were made at this stage, with a specific focus on building ideas around tensions in the healthcare delivery architecture (see below)

6. after journaling, full-text papers were revisited as needed, to investigate whether insights were fully captured and to test developing analysis against new or different insights.

Data extraction

Extraction of important insights began in the journaling, which informed our analytical thinking alongside journaling content. The first draft of the synthesis was based on a small sample of the papers (n = 15, five for each profession) and included CMO configurations built from data extractions and insights from the journaling process. Subsequent papers were journaled in batches and then folded into the existing analysis. Team members (JJ and CT) read and reread papers in tandem with the emerging analysis to ensure that papers containing causal insights were not missed on the first read. Second and third reading of papers was beneficial over the course of building the synthesis to identify and sometimes fill gaps, in particular in looking across the three professions.

Analysing the literature in stages

After the initial set of papers had been synthesised from the database search, subsequent journaling and analysis of reports (n = 7), literature reviews (n = 29) and middle-range theories (n = 14) was undertaken. As more content from papers was added to the analysis, the headings were reorganised and CMO configurations expanded and modified to account for the full range of data entered into the analysis.

The COVID-19 papers were also journaled using the appraisal journal technique and drafted into a separate analysis (see Appendix 3). The aim of this work was to extract key insights in relation to the abrupt changes brought on by the 2020 global pandemic. In terms of the health service architecture, the COVID-19 analysis reflects considerable changes in service architecture, such as the sudden surge in intensity of healthcare delivery, sharp changes in resources and protocols, and new interventions to improve conditions for nurses, midwives and paramedics given the difficulties of pandemic-era health service delivery.

Stakeholder group contributions to analysis

Four stakeholder meetings were held during the review (December 2020, June 2021, January 2022 and May 2022). All meetings were held virtually (using Zoom) and included some core research team members (at minimum CT and JM) and Diana Bass, a psychotherapist whose role in the study was to provide psychological support to stakeholders should it be needed. Overall, these meetings provided confirmation that our developing analysis was resonating with stakeholders and provided suggestions regarding important areas to extend or improve our emerging analysis. Some alternative theories and challenges were also shared, which aided our thinking. All meetings (except the first where personal stories were shared) were recorded (with permission from all attendees), and meeting conversations and entries into the ‘chat’ function and on online whiteboards (Padlet, enabling anonymous contribution) were transcribed and reviewed in relation to the analysis to enrich and provide further support or challenge to the analysis. All stakeholders provided permission for their contributions to be used in this way, and contributions have been paraphrased and included anonymously in this report. Stakeholder meetings comprised a mix of presentation from the work-in-progress analysis as well as participants sharing stories and insights from their personal experience (see Table 5).

Aim (a) to describe the differences in demographic, structural features of work (service architecture), and well-being indicators between nurses, midwives and paramedics, and also compare to doctors

We extracted and compared key demographic, service architecture (structural features of work) and well-being indicators for nurses, midwives and paramedics, as well as doctors. See Chapter 2, Step 1B for methods of the critical review we undertook, and Report Supplementary Material 1 for the full publication. 4 The comparison with doctors was important since this review built on CUP-1,17 which focused on doctors. Key differences that we found between the professions, that may be important to fully understand causes and interventions to mitigate psychological ill-health include the following:

• Demographic

  • Gender: nursing and midwifery are female-dominated, whereas doctors and paramedics are more balanced. Various social and economic factors (e.g. being more likely to take on caring roles, live in poverty and experience domestic abuse) can put women at greater risk of psychological ill-health.

  • Age: nursing, midwifery and paramedic science have ageing populations – this ‘demographic timebomb’72 means many experienced professionals will be leaving the profession in the coming years.

  • Ethnicity: there is greater diversity among doctors and nurses than midwives and paramedics. Those with lower diversity have higher vacancy rates.

• Service architecture

  • Turnover and retention remain problematic in all professions.

  • Nearly half of doctors were consultants, but much smaller proportions of staff held high-grade/band roles in nursing, midwifery and paramedic science.

  • Salaries were higher for doctors. There are significant gender and ethnicity pay-gaps across all professions.

• Well-being

  • All reported high job stress, particularly midwives and paramedics.

  • Sickness absence rates for nurses, midwives and paramedics were three times those of doctors, and presenteeism nearly double.

We concluded that sociocultural factors known to increase risk of psychological ill-health may explain some of the differences between professions and that these factors should be considered when designing strategies to improve well-being. Other key recommendations are included at the end of this chapter and in Chapter 7.

Aim (b) to provide a more detailed and nuanced understanding of why psychological ill-health develops in nurses, midwives and paramedics

In this section, we consider each HSE domain in turn, describing the nuanced causes that sit beneath each domain.

Aim (c) to examine the literature to understand better ‘who’ is at risk and ‘when’ including identifying the differences within and between our three professions of nurses, midwives and paramedics, going beyond demographic and individual characteristics to also consider the impact of different work environments

‘When’ are nurses, midwives and paramedics most at risk of psychological ill-health?

Several time points were identified when nurses, midwives or paramedics may be at increased risk of psychological ill-health. As well as when newly qualified (covered above), this included the following:

Key findings

• There are more similarities than differences in causes of psychological ill-health among nurses, midwives and paramedics.

• Some causes may be more prevalent or exacerbated in certain professions, or roles within profession (rather than being profession-specific). In most cases it is the service architecture that can increase risk rather than the profession itself.

• Some individual characteristics deserve greater focus in the literature to ensure greater understanding of causes and interventions. This includes ethnicity, sexual orientation and/or gender identity, and disability. Multi-level systems approaches are required that consider intersectionality and structural differences between professions.

• There is a need for targeted interventions based on specific workplace settings/service architecture, to support particular staff groups, and at specific times when they may be at greater risk of psychological ill-health.

Aim 1: describe the interventions that are evaluated and/or recommended in the literature

A total of 115 different types of interventions were either evaluated and/or recommended in the included literature. These spanned primary (n = 52), secondary (n = 46), tertiary (n = 6) ‘levels’, and multifocal (n = 11) interventions. A total of 71 of these were classified as being ‘formal’ interventions (including all tertiary and multifocal interventions) and 44 ‘informal’ interventions (see Tables 7–10).

Note: virtually all empirical reviews of interventions (and key reports) concluded with strong caution about the limitations of the evidence-base, being based upon studies that had weak designs and/or measures (e.g. lack of control groups, measures that had low reliability and/or validity) and inability to synthesise due to heterogeneity between studies.

The interventions are presented in Tables 7–10 and discussed according to their intended level of action below.

Aim 2: compare the types of interventions evaluated and/or recommended in the literature according to ‘type’ of paper, and professional group (nurse, midwife, paramedic)

Aim 3: assess the ‘fit’ of available interventions to the key causes identified in Chapter 3

The identified interventions were mapped to the causes identified in Chapter 3, based on the intended key aim of interventions. We then graded the causes: red, amber or green according to the extent to which interventions that tackled these causes existed in the literature (see Appendix 9, Table 29).

Note: important caveats are that (1) the literature we included may not reflect what is actually happening on the ground; (2) we did not run searches specifically for interventions aimed at these causes; (3) the mapping and categorisation process require an element of judgement and may not be comprehensive but is intended as a starting point for identifying major gaps between causes and interventions.

The results of this process indicated that for the majority of the causes, there exist some formal and/or informal interventions but more evidence and work is needed; areas where intervention knowledge appears strongest are for exposure to trauma (including experiencing death); there are several identified causes of psychological ill-health where there may be no interventions currently, this includes many of the identified profession-specific causes (and thereby the ‘who’ and ‘when’ factors), including service architecture features such as working on call; lacking continuity of care; unnecessary call-outs; high risk of sustaining injury; being a profession under scrutiny; lone working; fear of assault/abuse from the public/patients. We also found no interventions aimed specifically at supporting staff through investigations or complaints despite this being a known key cause of psychological ill-health.

Overview of key finding

Much previous literature has focused on descriptions or evaluations and syntheses of individual discrete interventions (potentially plug and play, ready for rollout), see Chapter 5. There is an implicit underpinning assumption that these alone may benefit well-being, without taking account of the wider context of the implementation of such interventions and the need for a dynamic ‘system’ of interventions contextualised to setting. We noted a prevalence of well-being solutions that are fragmented, individual-focused, with a non-aligned, incoherent approach, which conceptualises psychological ill-health as binary (ill or not) and focused on acute events rather than acknowledging any cumulative impact of work on psychological health. CUP-1 identified ‘It is also clear that complex problems require complex solutions, and so many interventions to tackle doctors’ mental ill-health are likely to be multi-dimensional and multi-level’17 (p. 57). CUP-2 found the same for nurses, midwives and paramedics and highlighted a dearth of multifocal system-level interventions (see Chapter 5), and despite many primary ‘organisation’ level interventions, many are policies or recommendations that should be implemented, rather than interventions that have already been implemented and evaluated. The ‘causes’ literature has often focused on acute traumatic incidents that lead to PTSD/secondary trauma, and by doing so has downplayed the cumulative impact and consequent ‘normalisation’ of low-level chronic stressors (see Chapter 4). We suggest a multilayered systems approach to psychological well-being is required; not a one-size-fits-all approach, but individualised and where everyday events, as well as acute events, are acknowledged as impacting staff psychological wellness.

One positive example was found in a review of support interventions for UK ambulance services staff22 who report that UK mental health charity Mind has undertaken more complex multipronged approaches to change culture in emergency services (including the emergency services psychological ill-health prevention and support the Blue Light Programme35,95 to try to get people to feel more able to talk about their psychological health and seek support. A second example was found within a report on nurse suicide36 Some of which suggested the need for evidence-based strategies to intervene at the personal, institutional and regulatory levels. The Blue Light Programme focuses on changing public perceptions of psychological health relating to front-line staff and seeking commitment for change from leaders, politicians and employers; setting up working groups and other activities designed to break down barriers and reduce stigma, as well as providing access to support via a confidential helpline. Another system-wide intervention strategy targeted at primary prevention (tackling the risk factors at their source) is the US Magnet programme now being implemented and evaluated in the UK. 180 This includes, for example, ‘shared governance’ and staff councils to enhance nurses’ and midwives’ roles in decision-making, fostering professional autonomy, exemplary professional practice and strong working relationships in multidisciplinary teams. Organisations that gain Magnet status have lower levels of staff burnout and provide safer patient care. Thus to support staff psychological ill-health often what is required is a long-term strategy to support culture change, not one-off discrete interventions. 30

Everyone is on a continuum from good well-being to psychological ill-health and moves along this in a dynamic way. An effective well-being strategy must acknowledge that solutions need to be situated within a multilayered systems approach that considers psychological ill-health to be a fluctuating state (not binary ill-health/well-being) resulting from both singular/acute traumatic events and from ongoing cumulative chronic stressors.

Tension 1: the tension between a focus on individuals versus a focus on systemic issues

We identified a number of individually focused interventions, chief among them were mindfulness-type interventions (see Chapter 5), which do have an evidence-base regarding effectiveness54,108,144 and, in the absence of other wider organisational interventions, may be useful to some staff in the moment. However, while studies demonstrate that mindfulness training has positive impacts at an individual-level, and may result in cultural change through spread,165 these impacts potentially represent a myopic focus in terms of the causes and solutions to workplace psychological health. In one paper, mindfulness-based interventions are described as empowering staff to increase their psychological flexibility (capacity to make choices in accordance with authentic values despite symptoms), but not targeting symptom reduction. 108 This suggests mindfulness increases agency but does not clarify what happens when agency is increased, particularly when an organisation may be downshifting the burden of resource scarcity onto individual staff.

Mindfulness may therefore place the responsibility on the individual to manage their stress and psychological well-being when issues such as staff shortages and shift patterns are not in the power of the individual to change. By offering access to such training and support an organisation may inadvertently send a message to such staff that problems in the organisational system of service delivery falls on their shoulders and they should become psychologically and emotionally strong and flexible to handle the consequences of such problems. This can manifest as victim-blaming health-care staff for not being resilient enough in the face of insufficient support from leaders/managers/organisations/government. Maben and Bridges suggest: ‘Treating resilience as an individual trait is seen to “let organisations off the hook”’181 (p. 2742). Yet, resilience is commonly defined as an individual’s responsibility and the ability to ‘bounce back’ after difficulty. 32,167 Bouncing back implies that you might have fallen apart but also that you are able to get back up again.

A report about resilience in midwifery34 concurs with the need to avoid an individual focus, stating that resilience requires ‘deeper investment in creating sustainable ways of being and interacting’ and they ‘caution against the introduction of resilience programmes that focus on individual change and ignore the significance of context’ (p. 34) stating that in the current climate there is a danger such an approach could become a ‘convenient salve’ for managers; similarly the SOM report25 stated ‘focusing exclusively on secondary and tertiary initiatives not only means that the underlying causes of poor well-being are not addressed but also implies that protecting mental health and well-being is the responsibility of the individual, not the organisation’ (p. 32). Stacey and Cook32 report an ecological model of resilience, which ‘makes the assumption that there is a fundamental connection between the complexity of the world we live in and resilience as a way to navigate that complexity’ (p. 2). Thus, some tensions in the health service architecture we have identified may be a product of organisational systems that are not approaching resiliency from an ecological point of view.

Other literature reports broader aspects of work contributing to burnout and work-life balance so that individual interventions would be unlikely to have an impact. For example, Gribben and Semple130 review the literature on the impact of work colleagues and the culture of the working environment, stating the importance of good relations with colleagues as well as informal interventions such as positive feedback, peer support, debriefing, concise open communication and positive role modelling, which are considered as burnout protective factors (see also Key finding 5).

Few organisation-wide interventions that might create culture change were identified in our sample of the literature (but see also Appendix 3: COVID-19). There are exceptions, such as the various ‘good practice’ examples in recent reports, for example,30 and those reviewed in Brand et al. 31 One of the few is Schwartz Rounds,48 which are open to all staff and have been identified as creating a counter-cultural space (no blame, a supportive and psychologically safe and containing space to talk about the emotional social and ethical challenges of work where hierarchies are left at the door and where there is no pressure to have outcomes) that over time changes cultures and supports staff to process work challenges. 48 However, in a national evaluation177 it was noted as difficult for band 5/6 nurses and midwives to attend (since they have half-hour breaks and no control over schedule), and we conclude it is likely to be the same for paramedics and community-based staff, who would also have geographic barriers to attending.

Note that in Chapter 5 we have drawn on the language of primary, secondary and tertiary levels to indicate where the focus and action of the intervention operates. As there was also some discussion in the literature of where agency for the intervention lay, upstream and downstream language was also used, which we explore further here. Drawing on health equity language, this problem can be summed up as a focus on downstream interventions (individual behaviour change and treatments) as opposed to wider salutogenic and potentially preventative upstream interventions (contributing societal and organisational factors and prevention strategies for the whole community). 182 This river metaphor is often used in public health, ‘Upstream intervention is like building a bridge to healthier lives, whereas downstream intervention is throwing a life ring to someone who is already drowning’183 (p. 1).

In terms of psychological ill-health, Bosanquet87 comments on the need to rethink psychological interventions for nurses and those co-designed, with input from front-line staff may be the solution, further refining this tension. The author writes, ‘well-being initiatives continue to focus “downstream” (…) aimed at enabling individuals to continue gifting care and going the extra mile for their patients/work colleagues/families. Despite the short-term respite that such initiatives can bring, they are a “sticking-plaster” formulated (…), to maintain the status quo’ (p. 5).

Examining papers reporting on downstream interventions,77,84,96,127,165 some comment on the problem of implementing downstream interventions without upstream support and resources and interventions, and also that an individual lens or individual-focused project may not achieve wider change. For example, in an evaluation of resiliency-based clinical supervision,127 in which nurses felt empowered to speak up through the programme, but then the environment was not conducive to speaking out (see also below), militating against wider change.

CMOcs#2 and #3 present rival theories about the granting of permission by managers for self-care, with the same resource offered resulting in different outcomes.

Damage can result from messaging sent by managers/leaders to encourage staff to self-care as it can appear that they are out of touch with reality. There is a risk of significant cynicism from staff where messages from management (e.g. take time to reflect, take a break every hour etc.) are not met with the reality of work conditions. This mismatch makes people feel leaders are paying ‘lip service’ to the problem or implementing interventions in a ‘tick box’ fashion.

Some studies, for example, described managers encouraging staff to engage in healthy activities outside of work hours to improve their psychological well-being in the face of stressful work conditions. Cedar and Walker96 note that organisations should not put the onus on workers as often it is organisational stressors that need to be reduced. Comparing with doctors, CMOc#2 links to CUP-1 (focused on doctor’s psychological ill-health) findings, in particular, CMOc#9,17 where stakeholders suggested: ‘focusing also on quality of work (i.e. making work a functional and meaningful part of doctors’ lives and fostering a sense of meaning within, rather than outside work) appears to be a stronger strategy to tackle work pressures and mental ill-health’ (p. 36). Miller56 offers insights into the conflict for managers between the organisational metrics and targets for service delivery (which often put additional pressure on staff), and the staff psychological ill-health narrative. Thus, any disclosure of issues by staff may be impacted by the fact that managers (who have a responsibility for their well-being) also have responsibility for service delivery and may be performance managed on metrics of service delivery.

Staff often feel pressure to keep going even when they are resource-depleted because ‘The culture is that you suck it up and don’t have a break, or you’re made to feel like you can’t hack it.’30 This represents a tension in which the messaging for granting permission does not fit with resources available and, as we have identified above, a perceived requirement from ‘top’ to meet patients’ needs, meaning staff put their own needs second.

In support of the benefit of ‘granting permission’ as an informal intervention, Andrews and colleagues84 argue that for nurses to engage in self-care they often need permission from others, including colleagues and superiors. Giving permission can thereby be seen as a mechanism of the informal architecture of service delivery. In this sense, an embedded informal strategy of ‘granting permission’ as part of the informal architecture can come from the ‘grassroots’ where, for example, one staff member may reach out to colleagues who are struggling and say, ‘hey, it’s OK to cry if you need to. Take care of yourself.’

Compassion and kindness to self are also important. Many managers will have worked even longer hours than their teams, setting an example, or supporting the workload. As the airline safety briefing say: ‘you must put your own mask on before assisting others. 184

(p. 7)

It is possible that a culture of giving permission can grow from the grassroots, especially when resources are scarce, or during times of exceptional difficulty such as during the 2020 COVID-19 pandemic (see Appendix 3). These mechanisms can be understood in two ways. One, in terms of managers and healthcare leaders reaching out and granting permission to staff individually or collectively, and two, they may encourage the workforce to grant permission to each other (top-down mechanism triggering a lateral mechanism). This is akin to the ripple effects of Schwartz Rounds: that through the openness and honesty with which work challenges and emotional situations are discussed in Rounds slowly over time leads to changing of conversations/culture outside of Rounds. 177 Granting permission can be enhanced through role modelling, especially by those in senior positions (e.g. in Schwartz Rounds). 177

Granting permission is an important first step, but the action still needs to be feasible in the context of the realities of practice. People need to see how this can be prioritised and incorporated into busy work environments and timetables, which may require some other things not being done. For example, what will staff not do to practise self-compassion through, for example, attending a Schwartz Round (reflective space) or taking time out for recovery in everyday practice. Multiple concurrent strategies layered upon each other (such as granting permission for self-care and role modelling self-care, for example) can create a context, but only when self-care and self-compassion become the norm, which can only happen in truly psychologically safe working environments. Managers and colleagues may adopt a commitment to remind their workforce employees and their peers to take time out and be kind to self and others. Granting permission has been described above as an example of informal service architecture but can also be built into formal interventions, such as TRiM,185 where after exposure to trauma, staff are warned that it would be normal to struggle with sleep and other aspects of life in the days immediately following the event, and if that struggle does not resolve, further support should be sought. However, time away from work while experiencing the impact of exposure to trauma is not built into this intervention. Also, even with permission, nurses, midwives and paramedics may be ‘hard-wired’ to be caregivers,84 which may override efforts toward self-care. Organisations that create a culture of permission for self-care can balance the reality of being hard-wired as carers and the consequences of service-delivery that involves trauma exposure.

Tension 2: the tension between a focus on acute episodes of trauma versus recognising and supporting chronic cumulative stressors

Theory suggests that staff can experience STS and vicarious trauma in healthcare work,186 but that ‘Vicarious trauma can develop in people who are exposed to other people’s trauma over a prolonged period.’186 STS occurs when exposure to traumatic events result in staff exhibiting signs of trauma themselves. STS is defined as ‘the natural, consequent behaviours and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person’ [Figley187 (p. 10)]. ‘The person with STS acquires symptoms by exposure to a traumatized individual and not from exposure to the traumatic event itself. ’188 STS appears similar to symptoms of primary trauma in terms of psychological and physical patterns, including potentially resulting in PTSD.

Furthermore, prolonged exposure to challenging service architecture such as low staffing, poor skill mix levels, unpaid overtime and steadily increasing work pressures is that staff: ‘make micro-adjustments to (…) work practices to cope with the increased work (…) (and) going the “extra mile” becomes expected, (…) by the time (they) realise that they have a problem, they may have already been seriously harmed by the system (the “boiling frog” effect)’. 189

(p. 1)

Chronic cumulative stressors and their effects on poor mental health need to be recognised just as much as acute traumatic episodes at work, and this non-acute trauma has been called everyday pressures:35,109

It is often the cumulative effect of less dramatic incidents rather than the major incident that impact our mental wellbeing... watching someone lose their independence, or escorting them from their home in the knowledge that they may never return can really hit home. 16

(p. 1)

It may take a while for the impact of these demands to manifest in terms of symptoms. 124

(p. 575)

In a paramedic literature review, Anderson94 reports Boyle (2007) identifying that ‘the most emotionally demanding are not those incidents involving the greatest physical trauma but the non-urgent ones, owing to the uninterrupted exposure to social emotions’. (p. 3)

Front-line staff and managers need to understand that both major and minor adverse events may trigger psychological health challenges and that the magnitude of the particular incident should not be the reason to judge the validity of the claim around lack of wellness. Staff also reported the need to move swiftly between very traumatic events (death of a child) to everyday stressors.

Quaile95 reflects on the harm caused by seeing and experiencing difficult situations as a paramedic:

it may be one shocking call, or it may be a build up over time, but I believe we are all affected in some way by the things we see, by the emotion we experience but are forced to contain while dealing with our job. 95

(p. 225)

It may be the case that a minor incident triggers a big reaction, perhaps because the incident is just the final straw in a long string of experiences that involve secondary trauma. Or it may be that the staff member connects to it in some way, as acknowledged in the SOM report:25 ‘Events are more likely to have a traumatic impact when they are unexpected, involve children or patient suicide. Additional risk factors for post-traumatic stress are when nurses and midwives can personally relate to the situation in some way, either through their own or a family member or friends experience’ (p. 20). If a staff member breaks down at what seems to be ‘the slightest little thing’, managers and colleagues will need to have sufficient psychological health awareness and training in order to recognise the patterns at play, and not judge the incident against the severity of the reaction. This is never more important than following the COVID-19 pandemic, when there may be a long recovery time after such traumatic exposure, which may make staff appear to react to ‘little things’, which may be triggers or cumulative trauma.

Secondary traumatic stress (STS) occurs when exposure to traumatic events result in staff exhibiting signs of trauma themselves (see CMOc#5). Trauma exposure may be acute or chronic and supervision and well-being interventions may require adaption to need. STS can also trigger buried unresolved personal trauma from events outside of work events. For example, Quaile95 (p. 224) notes

It (poor mental health) started to manifest itself after a failed resuscitation attempt on a child(…) While there were low-level symptoms (…) and (…) certain calls that would affect me more than others, there was much more severe recurrence after witnessing the aftermath of a plane crash.

Supervisors and staff may grant themselves more permission for self-care when there is a dramatic incident such as a road accident. Although even here some psychological preparation is necessary as our first stakeholder group identified.

However, if trauma exposure accrues from more mundane events, it may be more difficult to provide recognition of the need for support and space to process trauma, and the chronic may also become ‘normalised’ so no longer seen as needing support. 108,109,158 The relationship between dramatic and low-level trauma events needs further unpacking. Clarke158 described a personal story of burnout written by a midwife. The author described that for decades working in the health service they had never experienced burnout but had often been a support to others who were. This then changed:

I can’t identify a particular trigger (…) It was probably just a combination of events, including a new and challenging job and a particularly upsetting and traumatic clinical incident (…) I became short tempered and difficult to live with. I felt weepy and weary.

(p. 16)

Importantly, there was not one trigger but rather a combination of different factors. It may be theorised that negative impacts of chronic exposure to patient suffering creates an invisible cumulation of trauma exposure. In a new job, less well-known support mechanisms, especially informal networks, may have made this midwife158 less able to process the acute traumatic event. In support of this theory, when discussing risk factors associated with PTSD, Naumann and colleagues117 note that

a perception of reduced social support can be a risk factor for PTSD following traumatic events. Although no causal link can be made (…), a lack of mentorship, support and appropriate team behaviours were reported. A holistic approach to addressing these would be required (…) to reduce risk to its employee.

(p. 519)

When a breakdown happens, there may be a trigger incident that is large or small – releasing emotional tension that has been suppressed over time. This understanding is important so that an outsider to the experience (e.g. a clinical supervisor) does not unfairly judge and misconstrue the secondary trauma as the staff member not being able to handle small stressors. Managers can then be empathetic and develop appropriate responses to the need for staff self-care, even if there is no ‘smoking gun’ incident that explains a lack of psychological wellness.

Overview of key finding

Healthcare organisational culture ‘is a metaphor for some of the softer, less visible, aspects of health service organisations and how these become manifest in patterns of care’190 (p. 364). Following the Francis report, Harry Cayton, chief executive of the Professional Standards Authority for Health and Social Care, said that although the government had taken steps ‘it had not done enough to make (the NHS) more accountable and to allow professional responsibility to flourish (…) a balance had to be struck between holding people and teams accountable for their actions and fostering a ‘toxic blame culture that would make it harder to raise (…) concerns’. 191 A blame culture is

… norms and attitudes within an organization characterized by an unwillingness to take risks or accept responsibility for mistakes because of a fear of criticism or management admonishment (…) (It) evolves out of a bureaucratic management style that is highly rule-oriented compliance-driven (…)assigning blame or accountability to individuals even for system-level failures. 192

(pp. 314–5)

It is the opposite of a psychologically safe culture and prevents people from both speaking up and taking accountability. Such an organisational culture can be predicated on poor leadership, a lack of visibility of leaders, a lack of resources, and lack of support. It is often left to front-line workers to accept responsibility and, even then, the weakest link in the chain, such as newly qualified staff, may receive most blame. Thus, the person with the least influence or power becomes the one required to speak up and, at times, convey the need for shared responsibility, often to no avail. The NHS states it is a ‘no-blame culture’ establishment, yet an understanding of the mechanisms by which such a culture is created and maintained is not immediately apparent. The recent introduction of ‘Freedom to Speak up Guardians’ in the NHS is one intervention to support raising concerns and a no-blame culture. Yet, many of these Guardians identified a lack of resources, especially time, which negatively and significantly impacted their ability to respond to concerns raised effectively and on their opportunities to learn from speaking-up data and develop a speak-up culture. 193 During times of extreme hardship, such as the COVID-19 pandemic, when resources are scarce, and the challenges in providing patient care are clearly beyond the capacities of any one person, the causal mechanisms involved in an instance of a medical error can be diffuse and hidden; yet, an organisation may choose to find blame in a single staff member or team.

Tension 3: the tension between a lack of collective accountability, which blames individual staff for errors, versus a team/system-based approach

The starting point should be an assumption that everyone is doing the best job they can in difficult circumstances, rather than ignoring the contextual factors and assuming an individual is to blame. A no-blame culture can help to encourage as much learning as possible, as in other safety-critical industries. Amy Edmondson’s work on psychological safety notes healthcare work can feel interpersonally risky – for example, ‘asking a question that might expose your ignorance to others, looking incompetent when admitting a mistake or a weakness, or appearing negative or critical when pointing out a flaw in a process worthy of improvement. ’194 Psychological safety is a factor in helping people to learn new behaviours and overcome defensive routines. A lack of psychological safety is often found at the root of significant organisational errors and failures in a variety of safety-critical industries. On the other hand: ‘A climate of psychological safety makes it easier for people to voice tentative thoughts (and) (…) can help people override a tendency to default to silence, instead encouraging or allowing them to offer ideas, report errors, and speak up in ways that are vital for health-care improvement’. 194

A related issue is the lack of a framework for collective accountability in the NHS. As a result, staff may practice defensively because they know they will get the blame if something goes wrong. This can lead to being overly cautious or overtreating rather than doing what they feel is right for a patient, although there may also be advantages to having a named person responsible for example, permission to intervene.

The WHELM study74 (p. 20) reports

Midwives vividly described their personal concerns about the level of responsibility they carried and their feeling of “being under the microscope”. Their accounts suggested that they did not feel well supported by managers (…) (and) were also concerned that a widespread culture of litigation fear impacted on the care that women received, with a default to medicalised care to ‘err on the safe side… When something goes wrong, which inevitably will always happen, as sadly not every pregnancy ends well, however good the care, midwives are treated appallingly, it is shocking and devastating to observe good hard-working midwives torn apart by the absolutely disgusting way that incidents are dealt with. Babies do and will die, and it is not always somebodies (sic) fault. Trusts persecute individual midwives in order to cover their own back as far as litigation. There is never any support, it is truly a horrific witch-hunt. I have met so many broken midwives, who then leave the profession.

(p. 21)

The literature suggests that health professions’ training is so geared up to measurement and individual accountability, that for many staff it is hard to change this way of thinking and move to more system- and team-based approach. In light of unavoidable negative clinical outcomes, a whole-culture, system-wide change is advocated to help staff in striving to provide the best possible care, without blaming individuals or finding scapegoats. Relatedly, accountability and blame issues, while different, also link to inaction and highlight the need to understand systemic power that is found at the managerial level as well as at the front line. Individual clinicians may be held accountable by their employing organisation, and/or professionally by their registering body [Nursing and Midwifery Council (NMC)/Health and Care Professions Council (HCPC)], yet in some instances managers and senior leaders were not felt to have the same accountability and some double standards may exist. The negative impacts when managerial support is lacking for front-line staff are evident in one report:75 ‘participants [nurses] were visibly outraged and frustrated (…) that certain clinical areas were known to have poor standards of care, (…) [but] not addressed by managers. Participants compared this to their own professional accountability, where they were held responsible for their own actions and omissions, whilst (…) others were not’ (p. 10).

Highly empathic staff, especially those early in their careers may lack an awareness of larger systemic forces at play in service provision. However, they may still internalise and accept blame for events involving medical errors when, in fact, organisational leaders would also need to accept accountability. It can be hypothesised that the more self-reflective and empathic staff are, the more likely they will absorb blame for mistakes and internalise the effects of pressures, victim-blaming and bullying. Cull and colleagues89 describe the negative impact of blame culture on midwifery practice:

…many respondents commented on a perceived ‘blame culture’ in their workplaces, with a resulting impact on their mental health. One midwife described ‘coming home worrying about what I have missed, not documented, handed over [and] waking up with flashbacks’.

(p. e533)

Staff reflect on traumatic incidents and recognise that they were unprepared, thrown in at the deep-end, or unsupported. Healthcare is a complex workplace, and human error is inevitable. Nurses, midwives and paramedics in our stakeholder group told us that distress is often the result of feelings of guilt at mistakes and not being able to rectify them, as found in other reports and research papers. 28,83,137,195

It needs to be acknowledged that medical error and mistakes’ investigation is not about ‘protecting the interests of staff/staff well-being’ at all costs but about taking a contextualised view of the causes so that they are examined comprehensively. This needs to include an analysis of the context in which they happened, and the organisation needs to take responsibility and be accountable, as well as individual staff members. That way, there could be resolution for both patients and staff, and organisational learning.

Tension 4: the tension between needing to raise concerns to improve conditions and patient safety versus fitness-to-practice processes becoming an oppressive force

The service architecture associated with patient safety and related fitness-to-practice concerns contains several inherent tensions. On the one hand, mechanisms to identify fitness-to-practice concerns are needed to ensure that people who are not fit to be handling the demands of the job are identified and offered the care they require and perhaps even taking time off. Yet, fitness-to-practice mechanisms, if not implemented with care and sensitivity can become an oppressive force, resulting in staff dealing with their psychological health issues on their own, or not dealing with them at all. This can increase stress, trauma and risk regarding psychological health concerns in staff149 and such health issues may only become apparent when a critical incident occurs.

In reviewing causes and solutions to psychological ill-health, paramedics114 note ‘Concerns over fitness to practise can result in a “culture of silence” whereby staff don’t talk to their employers…If employees don’t come forward, employers won’t necessarily be aware of the problem and things can get worse’. (p. 192)

One study has investigated why UK paramedics have a higher rate of self-referrals to the HCPC than other health professionals,115 resulting in convictions and cautions. Some of the reasons they give include a pressurised work environment, variable guidance, variable support from supervisors, and work cultures of fear and conflict. Interestingly, an additional insight given was the fact that many paramedics have origins in the military and that ‘paramedics may be more habituated to rules and protocols than some of their applied health professional colleagues’ (p. 205). They write: ‘the third (reason for higher self-referrals in paramedics) relates to work cultures predicated on blame and punishment rather than shared learning from errors’ (p. 209). A punitive culture may be more prevalent in paramedic workplaces, yet these issues would be similar for nurses and midwives. Golden54 notes

When a midwife is (…), referred to the regulatory authority(…) this can cause a breakdown in the relationship of trust and confidence with the employer, leading to stress, reactive depression and possibly nervous shock. Sadly, there have been cases of suicide.

(p. 63)

In nursing, Marran147 also suggests it is not what is done that has such a detrimental impact, but rather how an adverse event investigation is undertaken:

The purpose (…) is to understand what has happened, so that appropriate actions and learning can take place. However, some healthcare professionals perceive the focus (…) [is] on apportioning blame, a perception that contributed to Wu (2000)196 devising the term ‘second victim’.

(p. 5)

In addition to the important relationship that staff have with line managers and organisational leaders, staff may also need to negotiate connection with external review processes in the context of medical errors, for example, to the NMC, and the HCPC. Such an external review may increase stress, as identified in CUP-1 for doctors43 and by registrants (including paramedics) referred to the HCPC. 28 A punitive approach and apportioning blame were identified in this paper149 for HCPC registrants undergoing fitness-to-practice investigations (FTP) where there was a significant psychological impact on many:

Their stories described influences on their wellbeing (...). A lack of information, long length of time for the process and poor support avenues (impacted) on the ability of registrants to cope with their experiences (…) (and) led to feelings of powerlessness, vulnerability and threat of ruin for many registrants. 149

(p. 1)

Recent changes in midwifery support and supervision were noted, as having increased stress for midwives. Previous in-house clinical supervision has stopped, and the supportive aspects of supervision have been replaced by the professional midwifery advocate model, which is non-mandatory and does not have any role in investigations. The regulatory role of supervisors is anticipated to lead to more involvement of the NMC as described by Barker:148

Currently, when incidents occur, midwives are investigated locally [and] (…) s concluded quickly [with] a plan introduced to (…) start the remediation process within weeks. When this is devolved to the NMC, it (…) may take up to 2 years to finalise, perhaps leading to more resignations.

(p. 826)

Secondary traumatic symptoms may also arise from medical error and the way organisations address issues around medical error. In a systematic review, Sirriyeh et al. 197 assess the effects of involvement in medical errors on healthcare professionals’ risk of psychological ill-health, noting an intense emotional response following an error with subsequent impact on the personal and professional lives of staff, particularly prevalent in blame cultures (see above). This includes acute stress disorder, suicidal thoughts or even suicide and these authors use the phrase ‘second victim’ to describe those who suffer emotionally when the care they provide leads to harm.

An incident that triggers traumatic memories from a personal life experience, or sudden and profound events, such as an unexpected patient death can have reverberating impacts that stay with healthcare workers long after the event resulting in them becoming ‘second victims’, with the incident leaving a ‘permanent imprint’ on them. 31 Marran147 reports shame, guilt, panic, shock and humiliation leading to self-doubt and loss of confidence as common feelings after making a mistake. She states that staff can feel personally responsible for any unintended harm to patients and doubt their clinical knowledge, and describes the term ‘second victim’ to denote

the negative psychological effects that making an adverse medical error can have (…) and the sense of alienation they can feel from their colleagues following the event (…). Second victims are doctors, nurses or other health-care professionals who have made errors relating to patient care and experienced psychological effects.

(p. e1)

Thus a second victim is a healthcare employee who experiences personal or professional impact as a result of involvement in a patient safety incident, or an error. 197 Marran147 also identifies the potential difficulty with healthcare professionals being identified as victims as

this may detract from the harm experienced by the patient (…) and suggests they lack accountability, yet (…)Lawton et al (2019) state they have rarely (…) encountered a healthcare professional who did not consider themselves accountable (…) and (such events) can result in significant harm to [them].

(p. 2)

A paramedic reflected on a child abuse case where the child died stating: ‘I’d often find myself just sat there not really doing anything but thinking about the job, and thinking about whether there was anything else I could have done. ’95 (p. 225)

Marran, in a literature review, describes a further example of a second victim, suggesting that the adverse event

left a ‘permanent imprint’ on them and the duration of the second victim’s recovery process may also be affected by any subsequent investigation, which can be protracted, uncomfortable and highly stressful. Second victims may fear making further errors, (…) (experience) loss of confidence, (…) all of which increase their risk of making further errors.

(p. e4)

She further suggests outcomes for staff can be poor: ‘Second victims often experience significant negative feelings and may question their skills and practice. This may result in unplanned absences from work, which places increased pressure on the rest of the workforce. In some cases, the healthcare professional involved may decide to leave their profession’147 (p. e4).

In midwifery there is significant fear of litigation and the WHELM report74 provides examples of midwives making second victim claims. Golden54 also notes that following a traumatic birth where the baby was significantly injured:

the midwife(…) makes a claim for nervous shock. The claim by the midwife is that the employer failed to protect her in her employment. The midwife claimed that the harm was reasonably foreseeable and that she was not party to the negligence that caused harm to the mother and baby.

(p. 62)

Litigation or fitness-to-practice processes implemented in a toxic work environment characterised by a lack of psychological safety and a blame culture may exacerbate symptoms of STS in staff who have made mistakes. However, Marran147 notes that when the process is well-designed, the majority of staff who have made an error report positive emotions such as ‘feeling motivated to improve their practice’ (p. e3).

Some authors (reported by Marran147) have also suggested that healthcare organisations can become ‘third victims’: ‘because of the potential negative financial and reputational effects they experience(…). In addition, adverse events can affect people not directly involved in the event. This could include patient safety professionals or others who are responsible for investigating adverse incidents and service improvement and involve them (sic) potentially becoming third victims.’ (p. 4).

This can affect the ability to hear staff voices and be willing to be open to hearing mistakes and providing a supportive environment for staff to learn in the future having detrimental effects on staff psychological ill-health. It is rare for NHS organisations to come to the defence of individual staff members exposed for medical error in the media, most remain silent and allow staff to be individually targeted, without recognising the organisation’s role in allowing a psychologically unsafe culture to happen. The research into the consequences for third victims is scarce and the implementation of a crisis management plan and associated measures are suggested to limit potential damage to an organisation’s reputation. 198

Tension 5: the tension between encouraging staff to speak up versus the ‘deaf effect’ response from managers and hearers

Healthcare staff who are encouraged to raise concerns and speak up play an important role in improving working conditions and in the detection and avoidance of harm to patients. 193 Yet, some staff feel unable to speak up and, if they do, their concerns may be ignored or responded to inappropriately. 199 Thus, fear of negative repercussions, organisational inaction, and the desire to ‘fit in’ can result in the silencing of employees’ voice. 193 In a recent review, Jones and colleagues (2021) also note the importance of ‘hearer courage’ to act on concerns. 193 There is some recognition in the literature that the culture in health care is not always that of a learning organisation where psychological safety is present in teams and where staff feel they can raise concerns without fear of retribution or consequences for their career. There is a long history of poor treatment of ‘whistle-blowers’ in the UK NHS. In the mid-Staffordshire scandal, for example, staff were accused of not speaking up but the inquiry found this not to be the case – staff were raising concerns and speaking up about poor care, but they were not being listened to, which authors in the field have labelled ‘the deaf effect’. 200 This term is used to describe the reluctance of those in authority to hear bad news from colleagues.

This is reinforced by the following excerpt taken from Twitter:

In the NHS: the standards you keep challenging destroy your mental health from the moral injury of repeatedly not being able to deliver even the most basic intervention care being left undone as there is not enough of you to do it in a timely manner(…) nor any meaningful way to change any of it. I have taken to the streets with a placard, been an activist. Raised concerns formally. Blown the whistle, yet here we are watching the service implode as staff leave in an act of self-preservation.

(@spearce33801- nurse on Twitter 16.4.22)

Some interventions are aimed at enabling staff to process, have a voice and speak up about aspects of work that need to change through discussion, for example, various models of clinical supervision including resiliency-based supervision. 12 Such interventions may incur unintentional harm to staff and increase mistrust in the organisation if they are not part of a ‘systems’ approach to well-being that recognises the structural/organisational causes of psychological ill-health at work. If an intervention empowers staff to voice concerns when conditions of work are not adequate to need, this may lead to a backfiring effect if there are no organisational pathways to take and action such concerns.

For example, Stacey127 reports on an intervention called resilience-based clinical supervision, which is ‘underpinned by the principles of Compassion Focused Therapy. The aims of such clinical supervision are to alleviate work related stress and support individuals to reframe their experiences through structured and reflective discussion.’ (p. 1). A main finding from that study is that even though the intervention was designed to give nurses a voice through reflective discussion, the facilitating supervisors felt a sense of burden and guilt around the fact they could not really address the problems that the nurses were raising. The nurses gained a sense of empowerment but then face the difficult realisations about systemic problems that are beyond their control. This disparity in having a voice, but that voice not leading to any change, may backfire and be detrimental to staff satisfaction at work and impact negatively on their relationships with managers and leaders:

in organizations where the culture undermined a clear process or commitments to responding to the distress of preceptees, facilitators felt overwhelmed and saddled with holding the emotion of their group (…). without a clear sense of how issues could be escalated (…) leading to a feeling of isolation. 127

(p. 5)

Overview of key finding

Nurses, midwives and paramedics are often thought to have a ‘calling’ or a ’vocation’ to undertake the work that they do. They are exhorted to ‘put patients first’, which some have noted may suggest they often feel they need to put their own needs second, with a culture of giving 100%. 90 Choflet and colleagues36 suggest ‘The prevailing nursing culture is “patient over self” when prioritizing time’ (p. 21) and for paramedics, Quaile95 reports that when staff attend an incident that is particularly traumatic:

they are offered some ‘time out’ but many staff don’t take this up when they know there are patients out there waiting (…) We are there to support the public in [their] time of need, but we tend to not to ask for help ourselves.

(p. 226)

This can challenge the maintenance of good well-being in the face of intense and potentially traumatic work. As we have already outlined, these staff work in a context of high demand, where high workload and being present at work to support the team or for the patients may mean staff neglect their own health and needs.

In CUP-117 CMOc#2 noted a ‘Normalisation of a high workload’:

When high workload and its negative consequences (e.g. distress, burnout) are normalised (C), overworked or sick doctors may feel they are letting down their colleagues and patients (M). This can contribute to presenteeism (O) and associated negative consequences on mental health (O1) and workforce retention (O2).

The needs of the system override staff wellness, with high-quality patient care being the primary goal.

Tension 6: the tension between a professional culture that promotes a ‘serve and sacrifice’ ethos, which persuades staff to prioritise institutional needs, versus a culture that promotes self-care

The literature included in this review indicated that professional culture often sends a message that staff must adopt a ‘service and sacrifice’ ethos and give 100% at all times, working long shifts with few rest breaks. For example, Barker156 and Bacchus and Firth90 report a healthcare culture that asks newly qualified midwifery staff to participate in a culture of giving of themselves to the service, with the latter90 noting that

giving 100% or more to prove their worth is [considered] a positive attribute in the midwifery workforce but can be used negatively to persuade compliance to institutional needs. Midwives work long shifts with little or no breaks due to heavy workloads, which has been termed ‘service and sacrifice’90

(p. 3)

Barker156 notes that taking care of self often rests with the individual (as noted in Key finding 1) with the exhortation for midwives to take care of themselves in stressful and difficult situations, often without the necessary support in place:

midwives (are required to) be able to demonstrate at the point of registration that they (…) (can) work in stressful and difficult situations, that they are able to recognize signs of vulnerability in themselves and colleagues, and (…)can incorporate self-care (…) while employers are not required to [give]support.

(p. 210)

Other literature reports the ‘desire to help’ may work against nurses by putting them at risk of compassion fatigue and vicarious trauma and comments on the need to rethink the deployment of well-being interventions for nurses, which continue to focus on the individual nurse, with such initiatives being describe as ‘sticking-plasters’87 (p. 5), and goes on to note that

even if we can create more person-centred cultures, the traits that draw us to nursing may work against us. Once such characteristic, the desire to help may, may put nurses at risk of compassion fatigue and vicarious trauma. 87

(p. 54)

Tension 7: the tension between supporting existing staff in the context of staff shortages versus perceived coercion to fill vacant shifts beyond contracted hours

Linked to the serve and sacrifice ideas presented above there was also a sense of staff feeling coerced to cover shifts when there are gaps due to insufficient staff. Consequently, front-line staff shortages present a major concern for the mental well-being of nurses, midwives and paramedics and impact work-life balance. Particularly as most of these staff groups work routinely long 12-hour shifts, with a review by Ejebu et al. 62 finding that ‘Shift patterns are often organised in ways that are detrimental to nurses’ health and well-being’ (p. 21). For example, Cull89 highlights the negative impact of being asked to fill vacant shifts during severe staff shortages:

Midwives described managers ‘begging’ for them to work extra shifts. Even if they did not agree to these extra hours they felt guilty. The requests impacted on their enjoyment, on their days off and they began to dread phone calls or texts asking them to work overtime.

(p. e554)

In the context of understaffing and pressure for staff to work overtime, the messaging that they are desperately needed is something staff may take home with them. Even on their days off they may think of work and feel like they are working. Some may feel guilty for having days off and not answering the call to do extra shifts and empathise with the consequences of staff shortages on colleagues and patients. It is possible that being asked to fill vacant shifts creates presenteeism. In a literature review, Freeling et al. 61 suggests

Johns (2010)201 found that hospital cultures that exalt loyalty, teamwork and professional identity can unwittingly encourage presenteeism (…). Further possible causes are the caring nature of the profession, the suboptimal health of many nurses, and intense job demands.

(p. 2)

The importance of on-the-job, and off-the-job embeddedness – in protecting well-being – is discussed in one paper. 88 Embeddedness in this context means ‘the extent to which people are linked with others or to activities, the extent to which their jobs and communities fit with other aspects of their lives, and the ease with which their respective links can be broken – that is, what they would sacrifice if they left’ (p. 329). The authors argue that the more fulfilled staff feel in their personal lives, the greater the buffer to the emotional challenges of being off duty while there is a huge need for staffing.

Tension 8: the tension between the lived reality of staff shortages versus the wish to deliver high-quality patient care, which can result in moral distress

This is supported by findings from one study that many staff are leaving the profession because they feel they can no longer give the quality of care their clients deserve,155 supporting previous literature on this;16,202 and care ‘left undone’ by Ball and colleagues203 who report that 86% of nurses ‘reported that one or more care activity had been left undone due to lack of time on their last shift’ (p. 116).

Staff shortages create highly stressful under-resourced work environments, which can create a vicious cycle and increase burnout and intention to leave the workforce, with associated middle-range theories of MD, moral residue and moral injury.

Moral distress was defined in the nursing literature in the early 1980s as occurring when: ‘one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’204 (p. 6). More recently, Morley (2021) defined it as the combination of (1) the experience of a moral event, (2) the experience of ‘psychological distress’ and (3) a direct causal relation between (1) and (2)205 (p. 15). Morley and colleagues report that MD has been found to be associated with feelings of anger, frustration, guilt, loss of self-worth, sorrow, anxiety, misery, dread, anguish, depression and nightmares; it appears to cause a withdrawal from the bedside, the avoidance of patient contact and loss of the capacity to care, with MD reported as an additional factor for nurses leaving or intending to leave their place of employment and the profession altogether. 205 Brooks206 argues that ‘It is equally important for managers to acknowledge the suffering that goes along with MD and give nurses the resources to address it. In their study an ethicist was available to consult with nurses, which happened frequently’ and participants suggested it was ‘a very important resource, but managers need to be open with nurses about (...) MD (…). It is, to some degree, inescapable, but if nurses know what it is, and have resources to help deal with it, then it can be reduced.’ (p. 1).

Jones193 reports that while COVID-19 has brought MD to more people’s attention, it is not specific to the pandemic and could be brought about by staff’s reaction to inadequate staffing levels or an inappropriate skill mix. Lena-Riedel et al. 207 report the associated concept of moral residue, when individuals are repeatedly exposed to morally stressful situations, from which they may not fully recover from the distress they experience. 208 Prolonged MD, which develops into a moral residue, can lead to moral injury, which can increase staff’s risk of developing psychological health problems and manifest in the form of a loss of trust in self, authority, and systems.

We identified two interlinked challenges: the vicious cycle of staff shortages resulting in the need to work harder and more intensively, and the challenge of staff shortages causing staff to work outside of their scope of practice, both of which may increase intention to leave (see also Chapter 4). A ‘runaway’ effect can occur with so many people leaving the profession that it creates an unworkable void in the environment for the staff who remain (as seen during and post COVID-19 – see Appendix 3) and so more staff eventually choose to leave. The King’s Fund report30 discusses this in relation to district nurses:

The King’s Fund has identified a large and growing gap between capacity and demand in district nursing services: a significant increase in activity over recent years, both in terms of the number of patients and the complexity of care; a decline in staffing levels, particularly in senior ‘district nurse posts’ an increasingly task-focused approach to care; and a lack of continuity of care (...). Inevitably, this is having a negative impact on staff well-being, with unmanageable caseloads common and come district nurses leaving the service as a result. 30

(p. 17)

This was also highlighted as one of the key pressures facing the NHS in an Royal College of Nursing (RCN) report:209 ‘spikes in staff sickness rates put even more pressure on services and the ability of staff to deliver safe and effective care, as remaining staff are even more stretched as they try to cover for those off sick’.

In our data, staff shortages led to further loss from the profession through another mechanism, in which staff are asked to perform tasks outside their role or job scope. For example,59 conducted qualitative research with midwives evaluating a preceptorship programme who suggested ‘understaffing means that you have to do more than you feel comfortable doing’ and that junior midwives ‘feel overwhelmed with responsibility and this can be a main factor that can impact on the sickness rate and staff retention’ (p. 10). Furthermore a paramedic systematic review21 highlighted: ‘it may be that staff shortages lead to an ambulance crew responding independently to a job that would otherwise require backup, making the job potentially more challenging and/or traumatic’ (p. 23). This was also reported in the SOM report25 and WHELM report74 where in the latter many midwives reported being moved around to plug gaps in service provision, making them feel undervalued, and causing stress and anxiety: ‘The perception that my role is not essential and the expectation that I can be used to plug gaps elsewhere means I am asked to work clinically in areas I’m very unfamiliar with, but where there is no support and it doesn’t feel safe’ (p. 19).

Undertaking tasks beyond their expertise and experience was particularly evident in staff who were redeployed during the COVID-19 pandemic (see Appendix 3) and by our stakeholders:

Overview of key finding

Healthcare staff are known to have a desire to help others and hold strong professional values. Evidence tells us that empathy and compassion and professional values matter to patients and for high-quality care delivery. 11,210 In the UK, nurses, midwives and paramedics personal and professional values are underpinned by the NMC and HCPC professions’ codes of conduct and the NHS constitution and six values therein (working together for patients; respect and dignity; commitment to quality of care; compassion; improving lives and everyone counts). Like empathy (identification with and understanding of another’s situation, feelings and motives)211 compassion is something that is felt and is a deep awareness of the suffering of another coupled with the wish to relieve it. 210 Thus, health-care professionals are exhorted to care about patients to empathise and to show compassion. Yet compassion and high empathy can come at a high price for staff in terms of their own psychological ill-health resulting in vicarious or secondary trauma.

To deliver compassionate high-quality care, emotional labour is required; nurses, midwives and paramedics often have to suppress authentic feelings and regulate their emotions, which can impact staff psychological ill-health. Emotional labour can be defined as an outward appearance of calm that does not reflect inner turmoil while comforting patients. 212 A potential so-called theory-practice gap is reported to exist between the theory taught in healthcare education and the reality of healthcare delivery. 202,213 If staff cannot deliver care in line with their values (see CMOc#14 above) this can cause guilt and MD or moral injury.

Tension 9: the tension between the reality of healthcare delivery versus the taught theory and values, which can lead to guilt and moral and emotional distress

CUP-1 programme theory17 identified that doctors did not feel able to do the job they were trained for or able to feel proud of the work they have done. Brooks21 suggests clinicians experience a high level of MD when they know they are not providing optimal care to patients. Our data also suggested the same was true, particularly for nurses and midwives with a theory-practice gap evident in a number of ways.

Published literature has alluded to the role of professional identity and role clarity as important determinations of psychological wellness for nurses and midwives. For example, a study on resiliency in midwifery214 in which they asked senior midwives what allows them to ‘bounce back’ after a difficult day. In that study, participants cited ‘having a strong sense of professional identity’ (p. 67), among other traits. Similarly, Goddard52 provides further insights into the role of professional identity formation on psychological health in the nurse workforce and issues of dissonance. In this study, they examined the prison nurse role and the challenges in maintaining a clear sense of professional identity in the face of incompatible ethos of prison administrative culture. They write ‘if there is a dissonance between what the nurse perceives to be essential values, ethos, and history and what which is encountered in the workplace, it could negatively impact on the growth of a positive professional identity’ (p. 165).

Some groups of staff seem to suffer more than others, with newly qualified staff often struggling the most, trying to implement theory and uphold ideals of care quality. 16 There is evidence to suggest that more experienced staff may have either had to compromise their ideals of care or left the professional because they had been crushed. 215 Hawkins et al. 123 in a review of the literature on new graduates describe the impact on them of working in unsupportive workplace cultures that have risk of

endemic bullying behaviour….aggressive acts are most often committed by nurses who are impacted by negative job characteristics, such as increased workload, emotional demands and role conflict (…) new graduate nurses (…) are often overwhelmed and stressed due to heavy workloads and inexperience.

(p. 42)

The reasons such staff are more at risk are because of their ‘inferior position within the nursing hierarchy (…) and the unrealistic expectation for new graduate nurses to hit the ground running’ (p. 42). They report that after 6 months of employment, nurses had their ‘ideal view of belonging to a noble profession replaced with being in a culture that eats their young’.

The literature on the causes of workplace-induced psychological ill-health (see Chapter 4) and solutions (see Chapter 5) point to the nature of job roles and the organisational conditions that form the basis of the work environment. A fundamental connection between job control and stress was summed up in79 in which the author states ‘Whether stress is perceived as positive or negative…is connected with a person’s ability to do something about the external stressor’ (p. 261). This implies that greater perceived autonomy over one’s work leads to a reduction of stress, burnout and attrition, as supported by the literature included in our causes chapter, and supported by organisational stress theory, for example, Karasek. 69

However, a tension also exists between the need for autonomous working conditions amongst team members and the resultant responsibility that comes with developing deeper relationships with patients and clients. For example, the midwifery literature has identified autonomous working conditions as an important factor in determining workplace psychological health. 34,74 Empirical survey findings from Yoshida76 revealed that ‘high levels of autonomy were a key protective factor of emotional exhaustion’ (p. 925). Autonomous working conditions can, in some instances, be compromised in the context of collaborating with other health professionals. In maternity care, this may involve a conflict in perspectives between obstetricians (medics) and midwives. Obstetric specialists may lead decision-making around maternal care from a medical perspective, which can be incongruent with midwifery practices, and poor teamwork between the multiprofessional members can lead to possible harms for the professionals and clients. Rocca-Ihenacho113 notes

organizational culture underpinned by teamwork, cooperation, and positive working relationships is a key characteristic of safe maternity units…maternity unit performance can suffer from a lack of focus on philosophy of care and that malfunctioning health care organizations with poor interprofessional relations are associated with catastrophic, avoidable harm to service users.

(p. 2)

Maben et al. 16 report nurses leaving due to an inability to implement their ideals and values:

On qualification nurses emerged with a coherent and strong set of espoused ideals around delivering high quality, patient-centred, holistic and evidence-based care (...) (yet) (…) within 2 years the majority experienced frustration and some level of ‘burnout’ as a consequence of their ideals and values being thwarted’

(p. 99)

This can cause MD and injury (see above). Newly qualified midwives can also experience cognitive dissonance between their original ideas around women-centred care provision and the reality in practice of the dominance of the medical model – the so-called theory practice gap202,213 – especially around issues of autonomous working:

…NQMs felt guilt and emotional distress at not being able to give woman-centred care…They were frustrated by their lack of autonomy and its effect on the women in their care, when taught at university to empower women to make their own decisions. 90

(p. 7)

Tension 10: the tension between the benefits of staff empathy to patients (ensuring quality care) versus the harms of staff empathy to staff (increasing risk of vicarious trauma or unhealthy/negative coping strategies)

When ill, frightened and/or facing a difficult diagnosis, it is reasonable that patients want to be cared for and cared about by those looking after them. 215 There is evidence to suggest that a caring healthcare encounter is highly associated with patient satisfaction,216 better patient outcomes217,218 and facilitates healing. 219,220 Indeed Kenneth Schwartz (a patient who died aged 39 of lung cancer and founder of Schwartz Center Rounds) spoke not only of the need for care and validation but also spoke of the need for empathy: ‘I have learned that medicine is not merely about performing tests or surgeries, or administering drugs… For as skilled and knowledgeable as my caregivers are, what matters most is that they have empathized with me in a way that gives me hope and makes me feel like a human being, not just an illness’221 (p. 3).

We have noted the challenges of this work; that going the extra mile and caring for others is desirable but can readily be undermined by resource shortages and healthcare professionals need to bring their whole emotional selves to work each day. Yet, often there is no support or training on how they can protect their psychological well-being when faced with a daily exposure to trauma, to sadness and to loss. Healthcare staff are recruited for their caring values, and encouraged to empathise with patients, yet they can experience vicarious trauma, which ‘can develop in people who are exposed to other people’s trauma over a prolonged period’186 and which result in secondary trauma for nurses, midwives and paramedics as outlined above.

Although there are repeated calls for the professions to recruit more people who exhibit empathic traits and whose personal values align with professional demands, empathic staff are at risk due to their ability to resonate with patient suffering. High levels of empathy are reported in one study to put staff at risk of PTSD. 100 They write: ‘empathic engagement with women is fundamental in maternity care. However, it is recognised to increase vulnerability to traumatic stress responses’ (p. 5). And ‘the midwifery profession may risk losing the most empathic midwives following traumatic perinatal event exposure’ (p. 18).

Similarly, too much empathy for others may potentially exacerbate burnout, as found in another study. 104 They write ‘according to reviews examining predictors of secondary traumatic stress, findings were mixed, but suggested that empathy was not protective, such that empathy had either no relationship or a positive relationship with secondary traumatic stress’ (p. 2).

In trying to find resolution to this paradox, staff may engage in coping activities that suppress their natural empathic gifts. For many empathic staff members, being repeatedly exposed to hardships of caring for patients coupled with a lack of support from their organisations and superiors may mean ‘turning down the volume’ on empathy to be able to cope. There is evidence that staff are often recruited with the ‘right values’, yet compassion and empathy can become eroded over time by a toxic system and, in a vain attempt to help staff protect themselves, covert rules suggest they ‘do not get involved with patients’ (keep an emotional distance). 215 Without an outlet to express one’s empathic gifts in service delivery, the real rewards of providing care are missed, leading to decreased satisfaction with work and reduced personal accomplishment, which is one element of burnout.

In the midwifery literature, there is an example of how midwives can at times establish processes that take control away from patients and their families to cope with the risks associated with providing care, and in particular to manage their ‘anxiety, loss of confidence, phobia and depression’ caused by the chronic stress they experience (p. 21). This need for control in the birthing process may be seen as a dysfunctional way of protecting against secondary trauma. Copp91 writes,

it is easier for a midwife to feel she has control in the birthing room, because this is her domain (…) and so she arranges for that to happen, unconsciously and through force of habit (…). So it seems that midwives can have a need to be orchestrating every person in the room

(p. 22)

Similarly, Barleycorn98 explains how staff may adopt a problem-solving approach void of empathy and connection to patients in order to cope. Although this may allow staff to function at work in the short-term, it may affect the patient’s (positive) experience, yet the underlying accumulation of secondary traumatic responses does not disappear and surfaces at some point. They write ‘emergency nurses will often have a problem-solving approach in emergency situations, this is termed as an ‘avoidant emotional coping strategy’ (a distraction) so they can carry on working. However, the long-term effects of this coping strategy can delay the recovery process and lead to the worsening of STS symptoms.’(p. 3). These examples and CMOc#20 link to middle-range theory developed by Isabel Menzies-Lyth (1960),222 whose classic paper on the structure of hospital nursing, (‘A case-study in the functioning of social systems as a defence against anxiety’). Menzies-Lyth suggested work in healthcare and social-care organisations entails significant anxieties for staff and that defences against this anxiety are part of organisational life. 222 Part of these defences (to defend against primitive anxieties aroused by contact with seriously ill patients), included depersonalisation, denial of the significance of the individual, detachment and denial of feelings and the attempt to eliminate decisions (and anxiety) by ritual task performance.

Tension 11: the tension between the excessive requirements for emotional labour inherent in healthcare practice versus the need to improve workplace psychological ill-health

The need to provide emotional labour and regulate emotions was identified in the literature as a requirement for the job, which has consequences for staff psychological well-being. 223 Hayes223 notes that emotional regulation occurs in two ways: the first is that staff have to provide positive emotional support to patients/relatives during times of acute crisis, regardless of what they may be feeling during those moments of crisis. At the same time, staff need to keep their genuine feelings at bay if they are experiencing secondary effects of trauma exposure. A midwifery paper reported that if midwives show distress and women see midwives crying this can impact on their feeling of safety, so midwives hide their emotions to support women in their care, which for staff further normalises these traumatic and distressing events. 224 Organisational expectations and pressures in the front-line emotional labour delivered by staff also play a role, as explained by Hayes et al. 223 in the context of paramedic practice:

An emotive response can appear insincere when it is acted, faked or actively modified to accommodate an organisational or societal norm (…) (however) certain human emotions (must) stay concealed; for example, revulsion at a horrific injury (…) this constitutes the effort that paramedics have to apply to their expressed behaviour.

(p. 320)

We are all affected in some way by things we see, by the emotion we experience but are forced to contain while dealing with our job. Showing any sign of emotion is still perceived as a weakness (…) and this is one of the things that needs to change. 95

(p. 225)

Anderson94 reports spaces in which different emotional rules apply for public and private performances of emotion for paramedics; with the on-stage performance with the public often using surface acting whereas the ‘debriefing in the vehicle or at the station – the off-stage arena – has been identified as an important coping mechanism employed by paramedics, providing a space to react “unprofessionally”’ (often with dark humour), with the backstage space at the home with family and friends. This draws on Goffman’s middle-range theory of dramaturgy, which uses the metaphor of theatre to explain human behaviour, describing front and back stages in presentation of self. Front stage is where individuals are expected to put on a costume and act differently when in front of an ‘audience’ and back stage is where individuals can relax and actions that would not be condoned in the front stage are free to be expressed. 225

Oates and colleagues111 in a literature review on nursing in a secure forensic mental health setting describe nursing in this setting as ‘emotional hard labour’ due to the likelihood of assault and difficulty of working with a disturbed and distressed patient group. Citing the implications for practice they, like other literature points to the importance of workforce planning that allows for ‘time out’ of the setting or early retirement (see Chapter 5). However, these strategies could be seen to be not really addressing the problem, just ‘minimising the dose’ of exposure.

Overview of key finding

Our synthesis of the literature also revealed several tensions in terms of identifying the ‘right’ intervention for the ‘right’ circumstances at the ‘right’ time. We also noted that although there is a plethora of interventions (both formal and informal) as outlined in Chapter 5, aspects of the service architecture can impede (or facilitate) implementation and there is often an ‘implementation gap’. 25,226

CUP-117 (p. 42–46) note four CMOcs that related to implementation challenges for psychological health interventions. These included the need for

1. endorsement [CMOc#16]; if not endorsed by the employing organisation and senior leadership, doctors may lack trust in it and may also feel frustrated if they cannot access it because of work constraints

2. expertise [CMOc#17]; if those delivering interventions do not have specific training expertise recipients may be less likely to trust the intervention, which may be ineffective and/or harmful or not accessed at all

3. engagement [CMOc#18]; if doctors involved in the development and implementation of interventions (recipients are more likely to trust and feel ownership of the intervention resulting in more use and effectiveness

4. evaluation [CMOc#19]; if the outcomes of interventions and the well-being of the workforce are regularly reviewed and monitored and acted upon then doctors may feel more supported and engage with efforts to tailor these interventions.

These features fit with evidence-based Implementation Science frameworks such as the CFIR,66,67 which tells us the factors important for successful implementation of interventions, and also with conclusions from the King’s Fund report,30 which states interventions are most likely to work when they are tailored to specific contexts and needs of the staff group they affect, and when they involve and engage staff in shaping and implementing changes. 25,227 In our synthesis, we have also identified the importance of considering who when and how interventions are delivered, not just what they are. This includes the timing of delivery of interventions; the mandatory or voluntary nature of participation in wellness interventions, as well as top down versus peer-based interventions (building on the engagement feature identified in CUP-1).

Tension 12: the tension between making staff wellness interventions mandatory versus voluntary

While we have identified the need for a dynamic ‘system’ of interventions and yet a prevalence of solutions that are individual-focused, which can make staff feel as if it is their responsibility alone for their psychological ill-health, we acknowledge that these interventions can be of benefit (within a suite of interventions) and some guidance about whether they should be mandatory versus optional, was identified in our synthesis. CMOCs#23 and #24 above present rival theories.

If an intervention is optional, some staff might not come forward even if they need help, perhaps due to perceived stigma associated with accessing help (e.g. one-to-one or group psychological therapy sessions). On the other hand, if an intervention is mandatory, some staff may feel forced to participate when they are not ready or feel the need to do so, or the offer of support may lack authenticity and feel ‘tick boxy’. This is explained in the following excerpt from a qualitative evidence synthesis of help-seeking in trauma-exposed emergency service staff:18

some participants resisted mandatory organizational mental health support following traumatic calls and Others, however, believed mandatory interventions would reduce stigma associated with their use and prevent delays to help seeking due to the stigma associated with disclosing vulnerability. 18

(p. 9)

It is known from the PTSD literature that psychological debriefing may interfere with natural recovery processes following a traumatic event18,35,103 and mandatory debriefing may not necessarily be the right intervention for a given staff member at a certain point in time. This potential harm is not always recognised by organisations, for example,

Midwives also reported an unhelpful organizational climate, and typically did not perceive responses from senior colleagues to be emotionally supportive. In addition, midwives who sought external input to help manage their responses to trauma were often referred to counselling services, despite counselling being contraindicated for the treatment of PTSD. 103

(p. 3)

Voluntary interventions may allow those who are most receptive to such interventions to take part and find benefit through connecting with peers and supervisors while allowing others to process emotional difficulty in different ways, such as through recreational activity, meditation and so on. Some voluntary interventions (e.g. Schwartz Rounds) may create a sense of psychological safety amongst the team/attenders whereby everyone knows no one is going to be forced into disclosing their difficulties (the audience can just listen and not share48,177). Normalising and attempting to de-stigmatise attention to and support for psychological health at work is also important, and if addressing/discussing well-being is a standing item on meeting agendas, appraisals, and other formal processes, and taken seriously and with good psychological safety then it may be helpful, but care needs to be taken that it is not just lip service, so how it is done is very important. In Duncan97 the authors argue ‘health and well-being concerns should be raised at staff meetings as a standing item, so it becomes normal practice for staff to think of their own health and well-being, as well as those of other team members’ (p. 480).

The theory here is that raising psychological health concerns as standard practice sends a message that people should monitor and reflect on their needs as part of normal everyday practice. Having group check-ins may also allow staff to think about their own and colleagues’ psychological health, which may increase recognition of the challenges everyone is facing across the workforce.

Tension 13: the tension between the need for spaces to debrief with managers/leaders so they hear and can thereby offer support versus the need for peer-led spaces for debriefing

We need both interventions for organisational learning (e.g. hot and cold debriefs) and those for staff healing (peer-led informal spaces, and counter-cultural organisation-wide spaces such as Schwartz Rounds).

CUP-117 note two CMOcs that related to this tension. These included the need for

1. positive and meaningful workplace relations (CMOc#7): which can foster a sense of belonging between colleagues and towards the profession and lead to an increased capacity to work under pressure

2. ‘organic’ spaces to connect (CMOc#11): with protected times and psychologically safe spaces to congregate staff can to bond over whatever is most important to them at that time, which may improve connectedness.

A recent review228 on shared social spaces on the wellness and learning of junior doctors identified four common attributes of positive social spaces: informal, safe, functional and legitimate, suggesting that informality was fundamental for a space to be positive for well-being and learning because

being away from the clinical ‘frontstage’ (…) allow(s) individuals to interact informally outside of the constraints of their usual roles (…) allowed social conversations to be ‘freewheeling’ and unguarded (...) (and) ‘backstage’ reflecting the degree of performance that must be enacted in the clinical environment.

(p. 6)

Our data support the benefit of spaces for staff to come together (see Chapter 5). It is known that over time such spaces and places for staff to eat and rest together have become eroded with break rooms often multipurpose rooms and not created with rests and recovery in mind, and ‘shared social spaces are in decline’ (Ulys under review). 228 Also, that certain contexts may make informal interventions more or less difficult to enact.

Thus, opportunities for staff to take lunch together or take breaks with other colleagues have been severely affected. This is particularly so for some specialist nurses,118 community nursing60 and midwifery staff and paramedics who are often lone workers and who may not see another colleague all shift, have less team support and perhaps more challenges around a manageable flow of patients. 60 While the importance of these informal spaces for peer-based support is acknowledged in the literature, so too is the importance of having support built into ‘the job’, as highlighted in our stakeholder group.

Other papers suggested trauma is an expected part of the job33,100,229 and a paramedic paper suggested the intensity of this exposure is at complete odds with what member of the public may ever see, with the general public’s perception of ‘normal’ different to paramedics114 ‘paramedics and ambulance crews see incidents on a daily basis that the average person may only experience once in a lifetime’ (p. 192). A paramedic review paper18 reported that due to the potential stigma arising from disclosing in earshot of colleagues, most of this defusing occurs in the private space of the ambulance when returning to base or awaiting the next call, and referred to the shame and fear of repercussions of admitting to psychological health difficulties. This may be more prevalent in a male-dominated work environment with military roots such as the paramedic service perhaps94 (also see Appendix 3). Although Choflet and colleagues36 suggest it also applies to nurses due to

a culture of personal and institutional stigma against treatment of mental health conditions, fear of judgment by peers and supervisors, consequences of having mental health treatment or condition on their ‘record,’ and potential action by licensing boards. (…) Addressing stigma, confidentiality, and reliance on self are (…)critical barriers to help seeking.

(p. 21)

The other tension relevant to formal versus peer-led debriefs is clarity about the purpose of any given intervention – is it outcome-orientated and designed to create actions for organisational learning or is it primarily for staff healing, or both? If linked to organisational learning it may be perceived as a ‘management tool’. The conditions under which staff would perceive debriefing as a management tool versus a supportive intervention is not clear in the current literature retained, but it can be understood in relation to the objection to having their well-being ‘managed’, and also in relation to other ‘objectives’ that the interventions may be serving (e.g. patient safety/organisational learning etc.). In our stakeholder group, a paramedic member stated that ‘how’ managers checked in with them – and their tone – mattered in terms of working out whether managers were checking in to check whether paramedics are OK to go to work (being monitored, with service delivery at the root), or whether it was a supportive check-in, or simply a ‘tick box’ exercise. Alongside feeling their well-being is being ‘managed’, staff might feel that they are being monitored and judged by their superiors and their peers and suffer consequences to their job and possible reputation. Noting the key issue of stigma in the literature,18,35,36,230 issues may arise in terms of gaining a reputation of ‘being weak’ in the context of other staff who seem ‘resilient’.

This reaction against ‘management tools’ is proposed as one of the key rationales for the benefit of peer-to-peer spaces. Peer-to-peer community practice approaches to debriefing and wellness check-ins are recommended in a few papers,73,119,181,231 with a further paper suggesting them as an alternative to formal mentoring or supervisor-led check-ins:82

formal debriefing, particularly following critical incidents, is offered within ambulance services, usually from occupational health. Limitations can arise if ambulance staff perceive debriefing as a management tool, rather than a method of recognising and managing occupational stress, creating resistance to treatment.

(p. 1)

This also links to the need for spaces that are deemed to be independent (from managers, the organisation), raised in a few sources including a report about burnout in ambulance service staff by the Larrey society153 within which a key action was to ensure access to independent counselling services. Similarly, O’Neill and colleagues78 examined supervision with nurses that used reflective practice techniques, which illustrated the importance of confidentiality and psychological safety and an uninterrupted safe space free of management as important for group support. They found that participants preferred that managers were not present during the sessions because they felt

it changed the group as people were afraid of being judged or told how to think or act. There were also concerns that managers may follow-up conversations outside of the group, which they preferred to keep private.

(p. 8)

Thus, informal confiding and sharing of experiences is most likely with colleagues (or family) with whom staff share a bond of trust. Without trust staff risk reliving distressing events and their feelings being invalidated. 18 A national realist evaluation of Schwartz Rounds (one of the few organisation-wide, peer-led, team-based interventions) identified the importance of confidentiality and psychological safety as important mechanisms to ‘disclosure’ healing and self-compassion. Schwartz Rounds have specific ground rules carefully prescribed by the programme architecture and facilitators to make it a safe space with a flattened hierarchy that overcomes any risks regarding disclosures with managers present identified above by O’Neill and colleagues,78 despite being a ‘formal’ intervention. Schwartz Rounds are one intervention to use stories and Paranjape124 discusses value of casual storytelling for reflective practice and self-analysis, while Quaile95 reports ‘Talking to my peers has also been a massive help … it helps me realise that what I’m going through is normal, and that many people experience things like this from time to time’. Similarly, Jackson73 reports the importance of being listened to and of peer support (in feedback about a support group for newly qualified nurses), also supported within the HEE report9 emphasising the power of peer-to-peer support to help develop a strong team ethos and that both formal and informal methods can be useful.

The use of technology in providing peer-led spaces was also reflected in the literature, for example, Webster57 who reports on the implementation of an online peer support group for newly qualified nurses. The approach is to provide an online platform whereby nurses can feel supported emotionally and ‘collaborate with one another to reflect on their work, gain psychological support, share power and responsibility, and feel empowered’ (p. 1587). The peer-led and voluntary nature of the intervention are important facets of the programme architecture, leading to the idea that nurses need to have autonomy around the restorative interventions they are provided. Such peer-led interventions can be assumed to be advantageous as a downstream intervention in the sense of increased psychological safety and shaping their needs, voice concerns and gain a voice in what otherwise might be a silencing and oppressive work environment. Alternatively, peer-led interventions may not always ensure psychological safety if peers do not have trusting relationships with each other, or if the volunteer moderation of the forum does not create a safe and confidential space for people to disclose sensitive issues and receive support; and the informal nature of some peer-led approaches may lead to staff not being signposted for further support when it is needed.

All staff, and especially mentors (who may be managers or people affiliated but not involved in line management) need to understand the impact of their actions on other staff who may be carrying secondary trauma. For example, the anonymous author of a blog116 writes about her struggles with psychological ill-health and how workplace mentorship has the power to cause and to heal deep wounds. She talks about how being yelled at by one of her mentors led to her spiralling down:

Sometimes it is the smallest thing that opens a crack, like a thorn in an open wound that is wiggled every time another ‘small comment’ is made, opening that space wider and allowing infestation and disease to spread deeper inward, until you are not quite sure who you are.

(p. 758)

The author described the impact of mentors being kind and patient, arguing that in some cases such acts of compassion can be more effective than resiliency training:

I think more effective than resilience is kindness, patience and gentleness. In my worst moments, I had kindness poured over me from hearts steadier than my own. I had ears that heard me and allowed me to speak, and many people who were willing to tread a path with me. This, more than anything, helped me to survive, heal and ultimately thrive. I am stronger, not by my own might, but by the strength of those that held me up when I couldn’t do it alone.

(p. 758)

A key contextual factor here for mentors/managers (or those doing the checking in) would be their training needs and ensuring that they were properly trained to ask the right questions and offer or signpost to the required support.

For example, Duncan97 writes ‘If managers notice that a staff member is becoming withdrawn and quiet, they should create an appropriate confidential environment to let the staff member know they have noticed, and that they are concerned for their welfare (…) [This might] prevent a difficulty from escalating to a problem’ (p. 480).

Tension 14: the tension between the need to act and offer support versus providing interventions that are ineffective because they are too soon, reactive and/or single time point

Interventions and strategies to reduce stress, can also be affected by the timing of the intervention. There has been significant learning in the recent COVID-19 pandemic where in a longitudinal study of the Impact of COVID On Nurses (ICON), nurses reported not accessing interventions, such as mindfulness Apps, ‘wobble rooms’, online ‘zoom’ well-being sessions, counselling or psychology sessions. This was due to a variety of factors such as time constraints and not wishing to access resources outside of shift-hours (while recuperating), or because of physical barriers such as sessions not being set up on the site staff were working on. Another reason was that they were not the right intervention at the right time: they needed their essential safety and physiological needs to be met first. 232 Indeed, in terms of temporality, in the ICON study nurses reported requiring very different support at different times; in the immediate crisis, they needed their immediate basic physiological and safety needs to be met as per Maslow’s (1943)170 hierarchy of needs [food, safety (i.e. personal and protective equipment [PPE]), shelter]. Once these were met, and the threat receded, they could begin thinking of accessing psychological support (if required). Thus, timing matters. Bowen99 reports an evaluation of a debriefing intervention for ENPs and found debriefing was not helpful for everyone and made some feel worse. This is a known risk with psychological debrief interventions that may be designed to mitigate risk of PTSD (such as CISD) but now known to potentially increase risk of developing PTSD. Another discussion in the literature concerns when in the shift such interventions be implemented. Winter120 reported findings on a particular debriefing intervention in midwifery called ‘recognise and reflect’, which is a debriefing intervention led by a specialist registrar and senior midwife, that takes place at the end of shifts. They explain that while this intervention aimed to provide opportunities to discuss positive aspects and any issues arising, the intervention failed:

However, these were abandoned after five weeks due to a 50% attendance rate, with one midwife commenting ‘I personally found at the end of a 12-hour shift, most people are impatient to return home/exhausted/drained’.

(p. 802)

This points to the fact that timing matters in debriefing interventions and that debriefings after long shifts may not be suitable due to fatigue and the need leave the workplace, unless time is built into allowing them to happen prior to the end of a shift. After a long shift would seem like a time when staff are checking out, moving into a different mode outside of the workplace context. Other examples in the literature included interventions that were not successful due to not being needed or wanted78 and another where the introduction of the intervention (restorative supervision and helplines) were reported as ineffective and unwanted. 87 Both studies reinforce the need for involvement of front-line staff in planning designing and implementing interventions.

What is missing from the literature?

Key gaps in the literature include

1. there are few system-wide, multipronged interventions in the empirical literature: our review found that the literature is replete with individual often one-off interventions; with few multifocal system interventions although we did identify some (see Chapter 5 and Appendix 3). Few of these have been evaluated well, likely in part to be due to the complexity (in methods, expertise and time) required for evaluations of multicomponent/systems interventions

2. the empirical literature prioritised acute or one-off traumatic incidents, rather than acknowledging the cumulative impact of everyday stressors

3. we found very little focus on intersectionality in relation to causes or interventions, yet it is critical to underpin strategies aimed at mitigating psychological ill-health in the diverse healthcare workforce

4. although our search strategy was not explicitly designed to locate economic evaluations of interventions, very few papers included this. However, recent work has made a strong financial case for investment in staff psychological well-being that was noted in some sources. 10,35

1. Exacerbation and acceleration of staff mental distress from already difficult pre-pandemic conditions

As indicated in previous chapters there was already substantial evidence pre-pandemic to indicate that nurses, midwives and paramedics were under considerable strain, with their psychological health suffering. Reasons included existing secondary stressors and Williams243 highlight ‘The huge importance of camaraderie, taking adequate breaks, having conversations with peers, reducing hassles over parking and eating, for example, demonstrated a decade ago, was re-emphasised’ (p. 7). The included literature provides strong indication that the conditions of healthcare delivery presented during the COVID-19 pandemic created an exacerbation and acceleration of staff psychological distress in relation to pre-pandemic workplace conditions,231,232,238,244 describe in one paper as the ‘perfect storm of psychosocial stress’245 (p. 380). We explore the reasons for this below.

Redeployment and new duties without sufficient training: staff experienced increased stress from being redeployed (being assigned a new role and/or moved to a new setting or area; usually to a COVID-19 ward or intensive care unit) in which they were required to work in unfamiliar environments and teams, often at short notice and without adequate training. 231,246

‘Deathscapes’; high numbers of deaths and distressing end of life care: nurses reported ‘Deathscapes’ (COVID-19 environments with high mortality rates) where care could not be well-planned, relatives and friends could not be present during/at end of life and so farewells were by telephone or video, with nurses present in intimate moments they would not have been before, and unable to hold patients’ hands or offer comfort as usual231 (48JM-CV). Other papers also highlighted the stress on paramedics, ‘where death has so frequently characterised the most severe cases of the virus’223 (p. 319).

Unfiltered, constantly changing global stream of information, government rules and clinical protocols: several included papers described the impact of constantly changing and differing messaging and protocols. 245,247,248 With Wong et al. 245 highlighting that COVID-19 was the first pandemic in an age of deep digital integration. Staff reported being exposed to constant streams of unfiltered clinical information and government rules and messaging that was constantly changing, reinforcing emotions of angst, confusion and despair, and frustration at the shifting and differing guidance at local and national levels: ‘Our clinical environment faces relentless increases in patient volume and acuity while we experience unprecedented physical and psychological hardship. In addition, conflicting and rapidly changing information regarding personal protective equipment fuels our ongoing fears of exposure and uncertainty about our own safety in the workplace’245 (p. 379).

Constantly changing directives led to great uncertainty in staff:

We were getting different information every day from different sources, from Europe, within maternity, within the Trust, from PHE (Public Health England), and I think everything felt very, very different…I found that a bit stressful, this conflicting advice and nobody being quite sure what’s the right thing to do. Do we break the Trust rules and do what we think is right ourselves?249

(p. 6)

The unique paradox of simultaneous global digital interconnectedness and social and physical isolation also shifted normal systems of coping. Front-line workers (e.g. paramedics) were being challenged to ‘both grapple individually with our emotions and to work collectively to support resilience among our colleagues.’245 (p. 379). Paramedics expressed frustration with the media scaring people into not calling for emergency support when they had valid reasons to seek help unrelated to COVID-19. 250 At the same time, they were being called to homes of people who were in a state of fear and confusion from watching the news and needed professional reassurances that they were not sick or dying.

Fear of contagion and virus spread: in the Impact of COVID on Nurses (ICON) study, nurses and midwives experienced considerable stress in terms of the fear around spreading the virus to their families and members of their households. 251 Similarly, paramedics reported developing traits close to obsessive compulsive disorder around cleaning and sanitising stations. 248 Furthermore, the ‘protect me to protect you’ messaging to staff, while emphasising the collective efforts needed to prevent transmission and interdependence of teams to practice COVID-19 safety, also highlighted the heavy burden of responsibility that all staff were facing. 248 The literature highlighted the sense of ‘guilt’ that nurses, midwives and paramedics felt if they were infected, firstly in terms of letting patients down, even when they were not at fault; and secondly letting each other down, for example, those sent home to quarantine may feel like they’re letting co-workers down. 252

Impact of inadequate PPE access/PPE wearing especially for interpersonal communications: COVID-19 was reported as causing greater and different psychological issues (to those pre-pandemic) due to concerns over safety (lack of sufficient PPE), staffing unpredictability and moral injury. 162 Maloney and colleagues247 discussed the psychological impact of high rates of patient mortality and the need for more specialised training for emergency medical staff around death and dying.: ‘even before COVID-19, performing death notifications was associated with increased burnout among EMS professionals. Appropriate targeted training in death notification procedures can mitigate this effect and may have become particularly important over the past year, with many areas seeing profound increases in unresuscitable cardiac arrest cases during the pandemic’ (p. 3).

Numerous papers discussed the impact of inadequate PPE. 231,245,247,253 Paramedics described feeling scared to transmit the virus from their patients to their loved ones, particularly due to fear caused by ill-fitting PPE, or being told to use PPE that was old and out of date. 248 Llop-Girones et al. 254 similarly discusses the lack of adequate PPE and how shifting policy around PPE put staff at risk. They write

Lack of PPE was commonly reported by many health workers globally, also in rural areas and the private health sector … Evidence shows that nurses who do not consider the availability and quality of PPE to be adequate had significantly higher levels of depression, anxiety, and stress.

(p. 11)

Various papers described the taxing use of PPE by nurses and midwives and paramedics during the pandemic. 250 This included the difficulty taking breaks and eating, going to the bathroom, and the additional time and labour caused by the need to don and doff PPE. 250 Paramedics often had to stay in full PPE for several hours while transporting a patient to hospital and waited for admission, and then had to spend further time and labour to decontaminate the ambulance after a COVID-19 patient transport, while concurrently receiving calls for more emergencies. Donning and doffing PPE often had to happen inside the ambulance en-route to patients and different patient cases required different levels of PPE based on a tiered system. 250

‘Tragic choices’ caused moral distress and injury: staff experienced MD in relation to making difficult choices with limited resources206,255 and those working on the front lines in ICU departments experienced high rates of mental health disorders and thoughts of self-harm. 241 The literature indicated that staff experienced heightened distress during the pandemic due to making ‘tragic choices’;248 personal; organisational and societal. Rees et al. 248 draw on the theory of Calabresi and Bobbitt who explored how societies allocate tragically scarce resources and make such ‘tragic choices’. Examples of tragic choices meant that inevitably some patients would not receive treatment.

An inability to always provide excellent care: paramedics and nurses reported feeling they were unable to deliver the standard of care they would usually provide and described how this could result in MD and injury,248,256 resulting in the following key message intended to aid managers to support staff:

It is important to acknowledge facing the moral strain and distress that staff suffer now and later when they are unable to do everything possible for all patients. This includes advising staff not to fill gaps by heroic actions that place them at greater moral and physical risk and not to raise their expectations of what should be done for patients. 256

(p. 8)

Rees et al. 248 discussed the rise of MD for paramedics when conducting home visits. Paramedics experienced decision fatigue and ethical dilemmas around advising (non-COVID-19) patients to go to hospital. One paramedic noted ‘I would say at least about 50% (of patients) are refusing to go in…so you are really having to convince and weigh up the balance of fighting against that, because if you do take them in and they do catch it and they do die, it’s weighing up the responsibility of that as well’ (p. 6). Mitchinson et al. 257 described the challenging circumstances in treating dying patients in intensive care:

Nurses struggled with the changes to care delivery: ‘as a gut feeling, as a nurse, you didn’t feel it was right what you were doing’ (Nurse, Palliative Care). Palliative specialists who would do anything to enable a good death and perceived themselves as ‘rule breakers’ (Nurse, Palliative Care) were now required to enforce policies which contradicted their care beliefs (p. 6).

Reports of losing the human side of care during the pandemic was prevalent across all our professional groups,231,238 illustrated for paramedics here

their interaction pre-pandemic with people with mental health issues was often tactile, involving holding hands and using nonverbal communication. Participants explained how the pandemic had significantly changed this: ‘the human side of our job has been taken away, and its really put into sharp contrast how much humanity we usually have in our job…personally I have found it really difficult leaving relatives behind and especially when you have got time-critical, possibly not going to survive patients. We had a lady with a very dense CVA (an early sign of ischemic stroke) the other day…and had to leave her daughter standing crying on the side of the road. 248

(p. 6)

The pandemic exposed health, global and societal inequalities. Several papers highlighted how the pandemic disproportionately impacted on those staff with minority backgrounds and revealed significant gender differences,258,259 yet we know that there is a link between inclusive environments and staff psychological well-being. 160 A Nursing Standard practice feature258 described reflections from black nurses and the extra risks that COVID-19 provided for this population, many of which were hidden and not talked about. ‘As a profession we are good at what we do, but not always good at sharing our problems with others’ (p. 41).

Gender, social class, ethnicity/race, age and migrant status were described as inequality axes254 that act as key relational mechanisms explaining why nurses (and often their families) are exposed to multiple risks and poorer health. They also highlighted other inequities such as pay rises being offered to many other public sector workers, including doctors and dentists but not to nurses. Similarly, inequalities were noted with regard to PPE:253 ‘Many health care workers (HCWs) reported failing their respirator fit-test and a lack of alternatives meant that they proceeded caring for patients with COVID-19 with these masks or used a lower level of protection. This was especially the case for female HCWs who experienced a lack of small sized masks and scrubs. Media analysis found reports of greater PPE supply problems for black, Asian and minority ethnic (BAME) HCWs. Powered air purifying respirator hoods (an alternative for HCWs with beards unable to shave for religious reasons) were especially lacking’ (p. 8). One paper noted that in some cases, stigma became associated with ethnic minority communities due to the higher rate of infection in those people. 260 This created an additional layer of stress of staff from ethnic minority backgrounds: ‘For a minority (of non-BAME staff), the apparent disproportionate impact of COVID-19 on BAME staff and patients generated a certain level of fear and stigma. A few non-BAME participants admitted that at some point during the pandemic, they had perceived themselves to be at greater risk of contracting COVID-19 from BAME colleagues and patients’ (p. 9).

Staff feeling undervalued and embittered leading to workforce attrition: the pandemic accentuated nurses extremely difficult working conditions and left many nurses, midwives and paramedics feeling undervalued and embittered. This caused some professionals to prioritise their own well-being or job-hop to try and find improved work conditions and intrinsic value in their work, which some had lost. 143

Innovation and immediate interventions introduced during the pandemic

The COVID literature highlighted both the on-going deficits in psychological support for staff, as well as some innovative calls-to-action that were established quickly as the pandemic emerged. Over the course of the acute phase of the pandemic (2020–2022), numerous interventions were made available nationally. 261 These included free access to mindfulness Apps and online interventions such as an online mental health forum SilverCloud;251 a network of NHS staff mental health and well-being hubs to support staff, which includes self-referral to NHS psychological talking therapies; and the implementation of the Professional Nurse Advocate (PNA) role (adapted from midwifery, providing ‘a safe and confidential space to allow time to reflect on and make sense of workplace issues’261 (p. 14) and restorative supervision. 261

During the difficulties of COVID-19, the literature indicates at least in some instances organisations improving their workplace culture and co-operation through rapid innovation, for example: ‘... the pandemic context appears to have simulated a significant amount of innovation and cooperation. For instance, the organisation initiated more provision of clinical support, better information, communication and digitalisation, factors which may have created an environment for improved professional growth. It should be recognised that such accelerated innovation and growth was forced rather than discretionary, which can occur to ensure the organisation’s survival and because it had to’248 (p. 9).

2a. National interventions were initially accessed minimally, healthcare staff preferring peer support and to connect with each other talk and be heard: online Apps and interventions were difficult for staff to access in their working hours and at home they often wanted to switch off and not think about work. Consequently, uptake was low,251 in one study only 12% of nurses and midwives reported using well-being apps to cope with the crisis; 17% reported making use of timeout rooms; and only 1% used the online mental health forum, SilverCloud. Instead, staff reported wanting peer support and opportunities to meet and speak with each other and such support was gained virtually through WhatsApp or Facebook groups:232 ‘What has been shown to help healthcare staff is peer support; opportunities for staff to connect with each other and share experiences, talk to each other and be heard by those who understand as well as more formal one-to-one talking therapy support as needed in due course.’ (p. 5). 232 The PNA role is relatively new to nursing and has not yet been nationally evaluated, but local evaluation from the first cohorts of PNA’s has been overwhelmingly positive with many reporting how the training had helped them become more self-compassionate. 261 A key barrier is that the time for providing support to others is not protected or built into workforce budgets, and staff need to undertake these roles on top of their day job. 261

2b. Access to psychological well-being services was limited with no paid allocated time and a reluctance to access in time off: the lack of paid allocated time to access psychological well-being services was highlighted in one paper:259

many HCWs had to take time out of their busy work schedules to access this [psychological] support, which was nearly impossible for overburdened HCWs. A consultant anaesthetist expressed her concern about the impact of this on certain groups, ‘I was quite surprised that there wasn’t (psychological support) particularly for the high-risk groups, so the ITU nurses and all the ward staff who are being pushed into ITU, stretching their skills in a very upsetting environment, weren’t being given allocated time, even on a fortnightly basis, paid to be there to get this psychological input and support.

(p. 7)

2c. Provision of formal psychological support did not always reduce stigma and some staff felt the need to be stoic and conceal feelings: the pandemic highlighted the importance of well-functioning mental health service provision, yet existing stigma and under-resourced provision prior to the pandemic had undermined this. For example, in a qualitative study on staff emotional well-being,262 it was noted that while hospitals increased the provision of formal psychological support available to staff, some (study) participants perceived a paradox, with implicit institutional rules that they should be stoic and conceal feelings that would enable them access to this support:

They used to do this (traffic) light system, like ‘amber’ and ‘red’, for how you were feeling, and you were encouraged to put your hand up in front of a hundred people to say how you were feeling. I think the pressure was for everyone to be ‘green’ at the beginning of a shift. It’s the wider feeling right now, to feel either amber or red every day when you come to work. But no one was amber or red. In a hundred people. I found it very weird.

(p. 14)

2d. Some taboos broken around staff psychological ill-health enabling staff to prioritise their health and talk about their experiences: one important positive finding included the breaking of taboos around staff mental health challenges so that people could start talking about what they were experiencing. Informally, the pandemic has created new norms for discussing psychological health amongst teams and networks of professionals. For example, McFadden et al. 263 noted that the pandemic helped to start new conversations around mental health in the healthcare workforce precisely because the changes in circumstances caused by the pandemic were so substantial that previously stigmatising disclosures of ‘not being able to cope’ became so common-place that the fear of being stigmatised was lost. Maloney and colleagues247 writing in the USA, talk about the stoic narrative, seeing the pandemic as an opportunity to ‘replace the traditional and stoic EMS culture of “be in control, suck it up, and move on”’ (p. 1) and a chance to advocate for emergency professionals’ own health and reflect together on the work they do: ‘Needing help and reassurance from others is human. Advocating for our own health must be seen as an intrinsic part of our duties to ourselves—and to others. This is not a call for non-productive criticizing and complaining, but rather more reflecting and confiding’252 (p. 2).

Trepanier et al. 264 report being inspired by the idea of the need for ‘psychological PPE’ advocated by the Institute for Healthcare Improvement in the US. The model includes encouraging individuals to take a day off and create space between work and home life; avoid unnecessarily publicity and media coverage about COVID-19; receive mental health support during and after the crisis; facilitate opportunities to demonstrate gratitude and reframe negative experiences. It also offers actionable interventions for leaders such as limiting staff time on site; clear roles and leadership with visible leadership key; educating managers to be aware of key risk factors and monitor signs of distress; instituting a buddy system and offering peer support services. 264

2e. COVID-19 well-being guideline development placed greater emphasis on individual level than organisational level interventions: akin to Key finding 1 in our realist synthesis (see Chapter 6), the COVID-19 literature placed emphasis on individual secondary and tertiary interventions. For example: ‘Box breathing is just one of eight quick and easy interventions designed specifically out of concern for the mental health of front-line workers during the current pandemic’166 (p. 177). The literature we reviewed was replete with discussion papers and reviews summarising what was known and developing guidelines. These guidelines placed greater emphasis on well-being at an individual level, as did other papers,167 rather than actions that should/could be taken at an organisational level, with few providing recommendations for both levels. 242 Vindrola-Padros et al. 265 recognise the benefit of organisations remaining agile in providing psychological support in times of acute distress for staff, but also the importance of adapting to the needs of local contexts:

…we would argue that these (well-being) guidelines need to be developed without losing sight of the realities of HCWs working on the ground, where fatigue and work pressures might not allow them to visit group support meetings or make use of quiet rooms for relaxation.

(p. 6)

Some innovative interventions were adopted or adapted during the COVID pandemic: in terms of innovative practices, there were several noted in the literature, including three that provide multifocal level (primary, secondary and tertiary) support at the team and organisational wide levels (Code Lavender,266 Healer Education Assessment and Referral (HEAR)36 and NOCA:264

‘Code/Team Lavender’ is an example of a programme that existed pre-pandemic but was adopted by more organisations in the USA to support staff during the pandemic. 153,247 ‘Team Lavender’153 is a hospital team-based peer support psychological health intervention that includes an interdisciplinary group of healthcare professionals dedicated to supporting co-workers during time of stress and/or hardship…and ‘although it does not replace the services of an employee assistance programme or mental health and psychiatric counselling, the approach provides dedicated time and space for initial emotional peer support, offering team members a moment of pause, reflection, and teamwork’ (p. 16).

The programme reported by Maloney and colleagues247 has two key components: (1) a proactive team is alerted and performs follow-up with involved responders after tragic or exceptionally stressful incidents or responses; and (2) a continuous pan-agency emphasis on both individual and group wellness, both physical and mental well-being, creating that safe harbour. When alerted, Code Lavender team members determine if they need to meet staff in person immediately after an incident, or if following up by phone or text is reasonable. ‘Importantly, this follow-up process extends for several days, if not weeks, beyond the initial call’247 and access to other (tertiary) resources, including therapy and support from chaplains, for example, was facilitated.

Healer Education Assessment and Referral was originally developed as a suicide prevention programme for doctors, but expanded to nurses in 2016 and other health workers soon after, and recommended in one paper as a promising intervention to mitigate psychological ill-health in a ‘peripandemic world. ’36 HEAR is a multifocal (primary prevention as well as secondary and tertiary referral) including a comprehensive educational programme, proactive screening for high distress and suicide risk coupled with ‘warm’ referrals, crisis intervention and critical incident debriefing for clinical units and their individual providers under duress, a peer support programme as a first-line intervention, and Schwartz Center Rounds, to share and discuss social, emotional and ethical challenges of their work in a safe space. 36

‘No One Cares Alone’ is a system-wide caregiver support programme123 within which coaching and support is provided by licensed behavioural health providers (BHPs), targeting leaders and the teams experiencing the highest stress levels. ‘Leaders are paired up with BHPs who can help navigate various available resources and develop a plan in partnership with their caregivers’123 (p. 57). The programme aims to be proactive, removing barriers to engaging help and interventions are bespoke and tailored, ‘It starts with creating space for conversation and taking the time to listen’ (p. 58).

In the UK face-to-face Schwartz Rounds were adapted at speed in 2020, to online sessions I called ‘Team Time’. These online sessions were shorter, more focused on specific teams (not organisation wide as Schwartz Rounds) and included sharing of more recent experiences and stories. 267 Gardiner et al. 230 highlighted a new programme (called Here4HealthCare) developed by a mental health association in Canada for healthcare staff. Such new efforts may improve the delivery of specialist psychological resources into healthcare settings and build bridges between mental health and healthcare sectors. The authors state: ‘Our case study should serve as a call to action for the governments at all levels to play a larger role in uniting capacity of our mental healthcare system and crafting a coordinated response to the emerging mental health crisis.’ (p. 88).

Sustained, longer-term changes and interventions arising from the pandemic

The COVID literature we reviewed described how the exposure of inequities and staff psychological health challenges led to calls for longer-term positive change to workplace conditions for staff psychological well-being. 238,268

3a. The pandemic has shone an important spotlight on staff psychological wellness and the importance of primary prevention: the pandemic has also exposed the importance of understanding staff psychological well-being through a wider holistic lens rather than solely individualised perspective. 269 Indeed, the pandemic has provided more visibility for the upstream causes and the need for organisation-wide prevention interventions. Maben and Bridges181 note that the health and well-being of the nursing and midwifery workforce had previously been considered important but not always an absolute essential priority. The COVID-19 pandemic changed this, by shining a light on the critical significance of the psychological well-being of healthcare staff, particularly nurses working on the front line. The immense challenges and trauma that nurses, midwives and paramedics experience during their working lives was finally being recognised and acknowledged with the hope that ‘When health care is back to ‘normal,’ ongoing support for nurses’ well-being will remain critically important’181 (p. 7).

3b. On-going psychological health requires support and investment for sustainability:

several papers noted the need for long-term/continued provision of support. 230,247,260,268 There was concern expressed about supportive provisions being scaled back, whereas the need for psychological support would increase postpandemic:260

Staff had felt valued by their employer during the pandemic and wanted to retain this feeling (...). However, almost all staff interviewed had concerns about supportive provisions being reduced in the future when the pandemic subsides, and they used terms such as ‘slipping back’ and services ‘dropped off’ when ‘the NHS goes back to more normal operating standards’. Most staff alluded to the impacts of the pandemic on staff mental health as long-term and they were worried about the emergence of more serious psychological problems later down the line once the immediate threat of COVID had subsided: ‘there’s gonna be a lot of, delayed stress, guilt, mental health impact, because people have been in survival mode for crisis.’

(p. 10)

Maloney and colleagues247 concur, highlighting the reality that the effect of witnessing tragedy does not go away overnight. Long after the public stop applauding healthcare staff as heroes, there will still be those who suffer the negative impacts of what they witnessed. Maloney and colleagues speak also of the guilt that can accompany healthcare work, when patient outcomes are less than optimal (through no-ones ‘fault’): ‘Not only do all of us need to find better ways to acknowledge and “forgive” ourselves for the human feelings of guilt, fear, betrayal, defeat, and the moral- and morale-injuring moments we experience, we also need to do the same for others and encourage a culture of safe zones among colleagues as we journey together through our challenges, past, present and future.’247(p. 1)

Neil Greenberg268 similarly advocates for the importance of adequate post-pandemic mental health resources for staff and a realistic longer-term plan, writing

A poorly implemented post-COVID-19 plan, leading to seemingly false promises of support or of time to readjust to the new normal or managers making high work demands on staff who have been working ‘flat out’ has the potential to derail staff support efforts to date and to cause serious psychological harm. Put another way, the unwritten psychological contract between NHS staff, their managers, and the public, has been that staff members will give their all to save lives and in return the nation will give them the support, and time they need, to be able to recover.

(p. 1)

3c. The pandemic provided an opportunity to change professional norms and for staff to reclaim autonomy and power and speak up and raise concerns: several papers noted the positive changes caused by COVID-19. For example, stimulating innovation and cooperation: ‘the pandemic context seems to have stimulated a significant amount of innovation, and cooperation. For instance, the organization initiated more provision of clinical support, better information, communication and digitalisation, factors which may have created an environment for improved professional growth.’248 (p. 9). Eagen-Torkko et al. 270 reflected on the impact of the rapid implementation of pandemic-related policies without much evidence, stating that it provided an important moment for staff (midwives in this case) to voice concerns and be heard. They write

It is not enough to note the effects of the pandemic on midwives and patients with a restrained clinical eye. Instead, midwives are ethically obligated to speak up, and speak loudly, when these policies create additional or unintended harms. Identifying and giving voice to harmful policies or practices creates the opportunity to resolve moral distress, by directly addressing the tension between what one can do, and what one should do, and to reclaim the sense of autonomy and power that is often lost in trauma (…) raising one’s voice can promote positive change for health systems, patients, and themselves. The sweeping wave of new policy brought by COVID-19 has the potential for harm but also the opportunity to enact change, and midwives can be at the forefront of that change.

(p. 306)

Yet it was not always easy for staff to speak up and raise concerns and challenge policies. Adams et al. 271 writes ‘The COVID-19 crisis has laid bare the question for healthcare professionals over how—and to what effect—they can raise concerns for themselves and their patients’ (p. 1) yet ‘some have reported cases of workplace bullying, retaliation, or threats of disciplinary action when raising legitimate concerns’ (p. 1). Abrams et al. 199 also report nurses’ and midwives’ fear of repercussions when speaking up and of organisations ‘deaf’ to those who did raise concerns (see also Chapter 6).

3d. Intervention timing is important (in COVID-19) – meeting essential needs in the immediate crisis with access to psychological support required later: the COVID-19 literature draws attention to the importance of timing of interventions and temporality. Citing Maslow’s hierarchy of needs and relating this to immediate and then longer-term needs in relation to the pandemic several authors note the importance of the right intervention at the right time. Wong et al. 245 note

(Maslow) provides a hierarchic context for how individuals prioritize their needs, starting from the most fundamental (physiologic and safety) and progressing to more abstract and complex needs once more basic ones are met (love and belonging, esteem, and self-actualization). 245

(p. 382)

This thinking has been applied to the pandemic by Maben and colleagues, following research with nurses during COVID-19,232 writing ‘Staff in our study required very different support at different times. Thus, in the immediate crisis, staff needed their immediate basic physiological and safety needs to be met as per Maslow’s (1943) hierarchy of needs (…). Only when these were met, and the threat receded, could they begin to access psychological support to meet these needs’170 (p. 12). Supporting this, Williams et al. 256 provide guidance for supporting staff during COVID-29, using a phased approach to understanding the needs of staff and what might be required to support them.

3e. An increased sense of camaraderie and pulling together during the pandemic with calls for this to be harnessed to increase cooperation and collaboration going forward: Baldwin and George272 noted the increased sense of camaraderie seen across the front-line health professionals because of the pandemic, and how this could benefit staff longer-term:

The pandemic has created a special professional bond among the staff where they felt that they were fighting this war together. In the military, bonds between team members have been reported to build resilience among troops, which echoes the messages from the participants in this study. Health professionals working together across professional boundaries is a welcomed move which will hopefully continue beyond the COVID-19 pandemic, resulting in more collaborative working among nurses, doctors and allied health professionals.

(p. 9)