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.
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.
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.
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:
- 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.
- 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.
- 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.
- 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.
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.