It was an article that started life as a conversation. We sat around a table in March 2016, discussing mental healthcare staff wellbeing. Someone pointed out the increase in burnout they had seen in mental health staff in the services they worked with; someone else spoke about the unique demands of working in mental health care settings, and how staff burnout may impact patient care. It felt like we were tapping important issues; etching out a line of argument we had not seen articulated in any academic articles we had read. Then I heard myself pipe up, “This feels like a paper. We should write a paper. I’ll draft it”.

Famous last words. As I left the room my enthusiasm waned a little. Had I really just volunteered to write another review?

Getting into the data
I knew I was going to need to access original data from government sources to build the case, which was new for me. I scoured NHS Digital and other sites, entering the numbers into excel files in order to plot graphs. These told me that the proportion of NHS  staff feeling unwell due to work-related stress had risen by 9% in 8 years (from 28% in 2008 to 37% in 2016; Figure 1a), and double the number of NHS staff had said they were leaving because of poor work– life balance in 2015 compared with 2011 (Figure 1b). I was stunned.

Figure 1

Figure 1. Percentage of staff reporting having felt unwell due to work-related stress on the NHS staff survey. (Source: NHS staff survey data; www.nhsstaffsurveys.com) (A) and number of staff citing poor work-life balance as their reason for leaving their NHS post. (Source: NHS Digital; https://data.gov.uk/dataset/nhs-workforce-reasons-for-leaving) (B).

Are these problems just in the UK?
The NHS has suffered significant underfunding for several years (Kingsfund, 2017) which has been a cause of staff stress, so I wanted to check whether these problems may be NHS-specific or similar in other countries. I found relevant data provided by the US Bureau of Labour Statistics (2017). Given the vast differences between the organisation of UK and USA healthcare provision it was an interesting point of comparison. This data suggested workers in healthcare support occupations take the most sickness absence of all employees, with rates 50% higher than private sector employees. It was clear that these patterns were not UK specific.

Are they any differences between staff working in mental healthcare and other settings?
Curious to compare mental healthcare staff with healthcare staff in other settings, I emailed NHS Digital to get a breakdown of sickness absence rates by trust type. These told me that mental healthcare staff are off work due to sickness on more days than the overall average for healthcare staff, and on more days than those in both acute trusts and primary care (Figure 2). Mental healthcare staff also more frequently cited anxiety, stress, depression and other mental health problems as the reason for this absence.

MH FIg 2

Figure 2. Sickness absence rate by trust type. (Source: NHS Digital: http://www.content.digital.nhs.uk/catalogue/PUB22562).

It occurred to me that the proportion of different types of staff varies across trust type. Some trusts employ relatively more doctors, and others relatively more allied health staff (such as occupational therapists and physiotherapists). What if this variation in staff type explained the variation in sickness absence? To test this, I restricted the analysis to first doctors, then nurses. It didn’t make a difference. In doctors in acute trusts, 17% of absences were in this category, compared with 26% in doctors working in mental health. In nurses in acute trusts, 18% were in this category, compared with 25% in mental health nurses (NHS Digital, 2017). It was quickly becoming apparent that the concerns we had raised in our conversation and the observations of members of the authorship team were backed up by hard data.

Impact on patient care
In order to consider the impact these high rates of stress may have on patient care, my co-authors and I reached into our knowledge of the general healthcare literature. A previous systematic review we had completed (Hall et al., 2016) found that high staff burnout is linked with greater risk of medical errors happening (or poorer patient safety) across healthcare settings. Medical errors can include being prescribed the wrong amount of a medication by your family doctor, being administered a medication you are allergic to by your nurse in hospital, or even being operated on the wrong body part by your surgeon. As expected, when we searched for studies investigating this area in mental healthcare staff a similar pattern emerged. For example, Brady et al. (2012) found that running a mindfulness-based-stress-reduction intervention with mental health staff improved patient satisfaction scores and decreased rates of patient safety events during the 3 months after the intervention. However, there was a disappointingly small amount of research linking healthcare staff wellbeing and burnout with patient care in mental health, and more is needed.

What about interventions?
There were also fewer studies looking at burnout and wellbeing interventions in mental healthcare staff than other staff groups, but I was pleased to find a recent systematic review and meta-analysis by Kimberley Dreison and her colleagues (2018) focused specifically on burnout interventions in mental healthcare staff. This review identified 27 studies. Interventions included stress management workshops, clinical supervision, and staff training. Overall, interventions were effective but only led to small improvements.

What type of interventions are most effective?
Interestingly, when interventions that focused on individual staff members (e.g., psychological therapy) were compared with those that focused on organisational changes (e.g., introducing staff support groups), individual-focused interventions were more effective. However, when staff training and education interventions were separated out from other types of organisational interventions, they led to greater improvements than individually focused interventions for overall burnout scores. This suggests that training and education interventions may be the best place for future research into burnout reduction in mental healthcare staff to focus on. It also suggests that simple comparisons between individually-focused and organisationally focused interventions could be misleading.

What now?
The purpose of the review was to produce recommendations for moving research and practice in this area forward. In the end, there were 4 of these:

  1. Ground interventions in the research literature: When developing burnout interventions, first understand what the causes of burnout are. Design your intervention to address this. Overall, the research literature suggests that poor staffing ratios, the emotional demands of caring for complex patients, lack of leadership and lack of training are all burnout contributors. Furthermore, draw on what the research tells us is likely to be effective. The best evidence at present suggests that staff training interventions may be particularly effective for reducing overall burnout.
  2. Increase the value of interventions: We know that staff burnout is consistently linked with quality and safety of patient care. It is also likely that these two operate in a feedback loop; not being able to provide high quality care is probably detrimental to staff burnout. Developing interventions which simultaneously reduce staff burnout and enhance care quality may meet two needs at once and be self-reinforcing. Again, staff training interventions would tick this box.
  3. Build bridges between universities and healthcare organisations: Partnerships between universities and healthcare organisations can help identify new and relevant topics for research, ensure studies meet current service and patient needs and help results to have a greater impact in the real world.
  4. Engage healthcare staff by emphasising the positives: There is a perceived stigma linked with admitting poor mental wellbeing in healthcare staff. Staff may fear that disclosure could cause career damage or put their professional registration at risk. As such, rather than offering burnout interventions as a fix for those who are struggling, emphasise the additional benefits that participants may reap. These include increased job satisfaction, life satisfaction, relaxation, and improved physical health. Be clear that interventions are not for the suffering but those who want to thrive in their work.

 

The article is published in the International Journal of Mental Health Nursing. To read the paper, follow this link.

 

References

Brady, S., O’Connor, N., Burgermeister, D. & Hanson, P. (2012). The impact of mindfulness meditation in promoting a culture of safety on an acute psychiatric unit. Perspectives in Psychiatric Care, 48, 129–137.

Bureau of Labor Statistics (2017). Absences from Work of Employed Full‐Time Wage and Salary Workers by Occupation and Industry. US Department of Labour. [Cited 18 November 2017]. Available from: https://www.bls.gov/cps/cpsaat47.htm

Dreison, K. C., Luther, L., Bonfils, K. A., Sliter, M. T., McGrew, J. H., & Salyers, M. P. (2018). Job burnout in mental health providers: A meta-analysis of 35 years of intervention research. Journal of Occupational Health Psychology, 23(1), 18-30.

Hall, L. H., Johnson, J., Watt, I., Tsipa, A. & O’Connor, D. B. (2016). Healthcare staff wellbeing, burnout, and patient safety: A systematic review. PLoS ONE, 11, e0159015.

NHS Digital (2017). Sickness Absence Full Time Equivalent Days Lost by Staff Group, Organisational Type and Reason for Absence. Dataset provided by the Health and Social Care Information Centre on request on 24th April 2017.

Put yourselves for a moment in the shoes of a sonographer, conducting an ultrasound scan on a pregnant woman. Perhaps her partner is there, and they are excited, smiling, and asking you the gender of their baby. Suddenly you notice an unexpected finding on the baby’s left arm; you can’t see his hand on this side. Perhaps it’s tucked just out of sight, but you can’t be certain.  He may be missing his hand. What would you do next? What should you say?

Make no assumptions

In the past this question has been answered too quickly. It has been assumed that the answer can be drawn from either 1) the sonographer’s personal experiences at work or 2) from research into how to ‘break bad news’ in other areas of healthcare, like cancer services. Both these assumptions are seriously flawed.

Parents’ reactions may be misleading

The first assumption is flawed because parents do not initially react based on how well the sonographer communicates this information. Instead, after hearing this news parents go into shock (Mckechnie et al., 2016). This means that the healthcare professional may do a great job of communicating the news and find the parents are extremely upset. On the other hand, they may do a terrible job and find the parents seem quiet and calm. The bottom line is that parents’ reactions at the time of the event are not a good indicator of a healthcare professional’s communication skills.

This experience is unique

The second assumption is flawed because delivering this news is different to delivering news in any other area of healthcare. In other areas of healthcare, the focus has been on ‘bad news’ (Baile et al., 2000), and this is not bad news, it is simply unexpected news. It also comes without warning; the parents are watching the sonographer’s face as they do the scan, and know as soon as something is out of the ordinary. Guidelines for delivering news in other areas of healthcare are not appropriate to apply in this situation.

Our research

It won’t come as a surprise then that in a survey we conducted in 2014, parents reported very low satisfaction with their experience of being told their baby had a limb difference (Johnson et al., 2016). To explore this area some more, we recently interviewed 20 parents (nine fathers, 11 mothers) who had had a baby with a limb difference in the UK in the last five years (for the full paper see HERE). Eight of these parents were told the news at an ultrasound scan, but 12 didn’t know about their baby’s limb difference until they were born. We asked these parents about their experiences of being told the news of their baby’s limb difference and how they thought this could have been improved.

What we found

Parents were keen to take part in the study. They had a range of experiences and while some wanted to participate because they felt things needed to improve, others were grateful for the excellent healthcare they had received at this time. However, all parents felt this was a defining moment in their lives: whether things had been done well or not well mattered. Receiving this news was the start of a journey into the unknown, and good experiences at the start had a lasting influence on how this unfolded.

Shock

In line with previous studies, all parents were shocked to learn their baby had a limb difference, but parents were less shocked when the limb difference was found on an ultrasound scan and they had time to process this news before their baby was born. They were also less shocked and less anxious when they had a friend or family member with a disability.

What parents want

Information about support organisations: Organisations such as Reach helped parents to find the right information and provided a support network. However, most parents only discovered these organisations through extensive online research and would have preferred to be told about these right away by the healthcare professional who told them the news.

Information about limb differences: While most parents wanted as much information as soon as possible about the limb difference, some said they felt overwhelmed and preferred to process the news at a slower pace. All of these parents said that being given written information would have been helpful.

Good communication skills: Parents wanted clear but sensitive communication from their care providers. In contrast to research in other healthcare settings, parents preferred it when healthcare professionals described the limb difference in a no-frills way, for example, “I cannot see your baby’s arm below their elbow on the left side”. Parents didn’t like it when healthcare professionals led into this with a warning sentence, like “I have found something wrong” or “there is a problem”. When this was said, it needlessly increased parents’ anxiety.

A care plan: Most parents felt frustrated about delays in their child’s health care; they described accessing appropriate care as a ‘battle’ and said they would have liked to know what their plan of care was going to be immediately. Only a few parents felt the plan of care they received had been good enough.

Some final pointers for healthcare professionals

If you are a healthcare professional, some final recommendations came out of our research:

Parents don’t like strangers appearing in the scan room: Some parents described being asked to go for a walk and returning to find a second sonographer in the scan room. For one parent, this was enough to trigger floods of tears, as she knew it meant something was wrong. Parents preferred it when they were warned in advance that a second sonographer was going to be invited in, and were given an honest rationale for this (e.g., “I cannot see your baby’s arm, so I need to find someone who is more experienced”).

Show that you care: Several parents said that they know delivering difficult news is hard for healthcare professionals and it is challenging to get this ‘right’. However, if they thought the healthcare professional cared, they tended to view them positively and be forgiving in any missteps in wording or communication.

Don’t panic: Parents appreciated it when healthcare professionals were confident and professional; when instead healthcare professionals communicated their personal shock at the dysmelia diagnosis (e.g., “this has never happened before”), parents felt more anxious and alone in their situation.

Insensitive questions are as bad as insensitive statements: When parents discovered the limb difference at birth, some reported being quickly asked insensitive questions. For example, one parent was being stitched up from her caesarean section when her doctor asked her what drugs/medication she had taken during pregnancy. The implication of questions such as these is that the parent has caused the limb difference by something they have done. Parents who received these types of questions too quickly found they had a strong and lasting negative impact on them.

 

References

Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES—A six-step protocol for delivering bad news: Application to the patient with cancer. The Oncologist, 5, 302-311. doi:10.1634/theoncologist.5-4-302

Johnson, J., Adams-Spink, G., Arndt, T., Wijeratne, D., Heyhoe, J., Taylor, P. J. (2016). Providing family-centred care for rare diseases in maternity services: Parent satisfaction and preferences when dysmelia is identifiedWomen and Birth29, e99-e104.

McKechnie, A. C., Pridham, K., & Tluczek, A. (2016). Walking the “emotional tightrope” from pregnancy to parenthood: Understanding parental motivation to manage health care and distress after a fetal diagnosis of complex congenital heart disease. Journal of Family Nursing, 22, 74-107. doi:10.1177/1074840715616603

 

The reference for the paper described in this blog is: Johnson J., Johnson, O., Heyhoe, J., Fielder, C., & Dunning, A. (2018). Parent experiences and preferences when dysemlia is identified during the prenatal and perinatal periods: A qualitative study into family nursing care for rare diseases. Journal of Family Nursing. In press. It can be viewed on the journal website HERE.