Breaking bad or difficult news in healthcare settings is challenging. What is the best way to tell someone they have cancer? How do you find words to say their treatment hasn’t worked? When I first became interested in this topic, I found a large body of literature had explored these questions. Studies suggested that the way difficult news is delivered has a lasting impact on patients’ subsequent symptoms of depression (Mager & Andrykowski, 2002), and that these events can have a negative impact on healthcare professionals themselves, increasing their stress levels (Shaw et al., 2013).

Despite this, one thing was still unclear: can this situation be improved? Can we train healthcare professionals to be better at delivering difficult news? This question seemed so big, so obvious, that my co-author Dr Maria Panagioti and I were sure it would have been answered before. We were surprised; while several individual studies had tested an intervention to break bad news, no one had yet systematically reviewed these studies and analysed the data together using meta-analysis. Meta-analysis combines results from multiple studies, providing better evidence about whether an intervention works and how effective it is than individual studies can provide. At first I was frustrated, why had no one done this yet? My frustration was quickly replaced with a sense of anticipation: if no one else had done it, there was an opening to do this ourselves! We got to work.

The search process
We decided to focus our review on doctors. We searched databases for potentially relevant studies and identified 2,270 records altogether. We filtered these by reading their abstracts, leaving 71 studies for more careful inspection. After reading the full texts of these, we excluded a further 53, leaving 17 studies for inclusion. The studies we included were from a range of countries, including the United States, Hong Kong and Israel. They were also from a range of healthcare settings, including palliative care, obstetrics and primary care.

Does training improve doctors’ skills in breaking bad or difficult news?
Altogether, the studies provided data from 1322 participants to answer our main question. The results of the meta-analyses were clear: interventions improved doctors’ abilities in breaking bad news with a large effect size. This effect wasn’t explained by sources that can bias results (such as the included studies being low in quality). Interestingly, interventions were most effective when they used an established framework for news delivery, known as ‘SPIKES’ (Baile et al., 2000). SPIKES outlines clear steps that doctors should follow when delivering bad or difficult news, such as delivering a ‘warning shot’ before breaking the news itself.

Could training help doctors too?
We asked a second question of the data, which was whether interventions can improve doctors’ confidence in delivering difficult news. Again, the results were clear: interventions improved doctors’ confidence in news delivery with a medium effect size. This suggests that difficult news delivery training may be one way to help reduce the stress levels of healthcare professionals who are regularly involved in these events, which is important considering current high rates of burnout in the healthcare workforce (see my previous blog on healthcare staff burnout here).

What now?
It is now clear that physicians can indeed be trained to deliver difficult news, and this training both improves their skills in difficult news delivery and also their confidence. What is less clear is whether such interventions can improve the experience of patients receiving this news. We only identified one study which looked at this. This study was based in Japanese cancer services (Fujimori et al., 2014). It found that when physicians were trained in breaking bad news, their patients reported significantly lower depression and anxiety symptoms later on, although the effect size was small. Further research into patient experience is warranted.

A need for further research in obstetric settings
One area future research on news delivery should focus on is obstetrics. The challenges in this setting are particularly complicated, as expectant parents may have no reason to think there is anything out of the ordinary with their pregnancy. Furthermore, if a healthcare professional has identified that a baby has a disability, it can be hard to know the extent of this before birth or how it will affect their lives. Our own research suggests that some parents still have a terrible experience at this time, which leaves a strong emotional imprint (Johnson et al., 2018; for my blog on this see here). Future research is needed to understand how healthcare practitioners working in obstetrics can be better trained and supported to deliver difficult news.

To read the review discussed in this blog, see here.

As a clinical psychologist by background, starting out in patient safety research was a learning curve for me. Suddenly the outcomes being discussed weren’t mental health symptoms, they were avoidable patient deaths, medication errors and patient falls on wards. Another thing I began to hear about was the aviation industry. Practices from aviation had inspired early patient safety researchers and I came to understand that we had learned much from them. For example, they had introduced standardised reporting and embraced psychological approaches in order to understand the group behaviours that contribute to safety failures (Helmreich, 2000).

More recently, however, this idea has fallen from popularity. When Jeremy Hunt attended a hospital Q&A earlier this week, he used this analogy. @Dr_Sarah_H, an emergency doctor at the hospital, challenged him on it. She later tweeted the problems with this comparison, highlighting the relative complexity of healthcare to aviation, the lack of control staff often have over their workload and issues with understaffing in hospitals. Her string of tweets went viral (below).

 

A couple of days after seeing these tweets, I was contacted by an experienced RAF professional keen to share with me the things he believes aviation do which healthcare can still learn from. He said that the RAF:

  • Have both open and confidential reporting processes in place which are simple to use; with confidential reporting, should someone have a concern they feel they can’t raise through normal reporting channels, they can submit a confidential report which by-passes all channels and goes direct to the RAF’s Safety Centre where it will be investigated by an independent team whilst respecting the confidentiality of the reporter.

  • Reporting is viewed as the life-blood of the Safety Management System so some stations have introduced a monthly award scheme for the best report which is awarded by the senior officer on the station.This is aimed at those who report a ‘near miss’, even if it is due to their own honest mistake.

  • Every report is logged and investigated, with feedback provided to the reporter.

  • Everyone receives Human Factors training during which real-life case studies are used to draw out the key learning points.

  • To avoid ‘witch hunts’ which damage the reporting culture, all investigations take place under a strict ‘just’ culture by an independent team. Incidents are rarely found to have occurred due to a single factor; almost invariably a host of contributing factors are identified.

In summary, the aviation industry enables their staff to report in utter confidence and rewards staff for good reporting. I think it would be hard to deny that healthcare still has a long way to go to meet these standards. Perhaps the contention then, is not Jeremy Hunt’s point but his target audience: does he expect NHS emergency nurses and doctors to implement these changes? Unlikely. Telling staff working in underfunded services to achieve the safety levels seen in aviation will only engender frustration, the sense that they are not understood and that the impossible is being asked. As with the RAF, these changes will require leadership support, resource and buy-in from the highest levels.

A previous post looked at the negative impact of staff burnout on patient care. But how can we tackle this problem? In this post I will consider the evidence for the effectiveness of interventions for reducing burnout.

Types of interventions
Interventions to tackle burnout are often broadly split into those which are targeted at the ‘individual-level’ and those which are targeted at the ‘organization-level’. Individual-level interventions are context independent; they view employees as people who are suffering from poor mental wellbeing and aim to treat this. They may include stress management workshops, one-to-one cognitive therapy or the provision of support phonelines for staff. Organization-level interventions on the other hand are ‘context dependent’; they view employees as workers being impacted by difficult work circumstances. They may include the changing of shift-patterns or rostering practices, improving canteen facilities or the provision of job training.

Are organization-level or individual-level interventions most effective?
There is debate as to which type of intervention is most effective. Three recent meta-analyses have found somewhat conflicting results.

  1. In a meta-analysis of 15 randomised trials and 37 cohort studies in doctors, West et al. (2016) found that while organization-level interventions were more effective than individual-level interventions for overall reducing overall burnout, there was no difference when the outcome was either of the specific facets of burnout (emotional exhaustion and depersonalisation).
  2. In a meta-analysis of 20 randomised controlled trials in doctors, Panagioti et al. (2017) found that organization-level interventions were significantly more effective than those which were targeted at the individual-level.
  3. In a meta-analysis in mental healthcare professionals, Dreison et al. (2018) found that individual-level interventions were more effective than those targeted at the organization-level.

Why the difference?
These conflicting results could partly be due to different interpretations of what the categories of ‘individual-level’ and ‘organization-level’ interventions include. For example, whereas West et al. (2016) included communication training interventions in with individual-level interventions, Dreison et al. (2018) regarded these as training interventions, which they included in with organization-level interventions. The lack of clear findings could also be an artefact of how broad these categories are; when Dreison et al. (2018) broke down the category of organization-level interventions into training interventions and non-training interventions, their results differed again; training interventions were actually more effective for reducing overall burnout scores than individual-level interventions. It is possible that the categories of ‘organization-level’ and ‘individual-level’ interventions are so broad as to be useless.

Take home message
Despite the confusion over organization-level vs. individual-level interventions, the clear message is that overall, interventions ARE effective. DO SOMETHING and there is a good chance your staff will benefit.

Helping staff to love their work
A first step in developing any effective burnout intervention should be to look at the causes of why this burnout has developed in the first place. This may sound obvious but it is often overlooked. Studies into the causes of burnout have identified several contributors which interventions could seek to address, including poor staffing ratios on wards, lack of time for patient-facing work, inadequate IT facilities and lack of training or professional development opportunities. The unifying theme here is that we need to help staff to love their work – we need to help make the difficult aspects of their work more manageable and support them to maximise and capitalise on the parts of the job they love. A recent example of this is the introduction of a caseload-carrying model of care to midwifery in Australia. Caseload-carrying midwives follow the same women up throughout their pregnancy, rather than simply attending to women who arrive at a clinic when they are working (who will likely have their other appointments with different midwives). There were concerns that carrying responsibility for a caseload may increase the burnout levels of midwives, but in fact the opposite has been found. A study by Dawson et al. (2018) found lower rates of burnout and more positive work attitudes in caseload-carrying midwives than those working in the traditional model. If we consider the causes of burnout, we could hypothesise that caseload-carrying midwives enjoyed stronger relationships with the patients that they had and were able to employ and develop a greater skill-set due to working with women at all different stages of pregnancy.

I work in healthcare. What can I do to help myself?
Research suggests that making changes at the level of the organization is a key to targeting healthcare staff burnout. However, if you are a healthcare worker keen to improve your own self-care, there are things you can do:

  1. Help yourself get good sleep. A recent study suggests that people who get better sleep are less likely to report burnout three years later (Elfering et al., 2018). If you work night shifts, getting good sleep may be particularly difficult for you. The BMA have recently published tips for managing these. Amongst other things, they suggest taking naps of 10-20 minutes during the early part of night shifts, avoiding caffeine and nicotine in the final few hours of night shifts, and wearing sunglasses on your journey home in the morning, even on a cloudy day.
  2. Put in boundaries. Nurses who have clear boundaries between their work and home lives have higher wellbeing (Oates, 2018) and psychotherapists who put in boundaries on an emotional level between themselves and their clients (Simionato et al., 2018) have lower burnout.
  3. Spend time relaxing, listening to music and being out in nature. Nurses who do this report higher wellbeing (Oates, 2018).
  4. Look into training opportunities you can access via work. The budgets for Continuing Professional Development have been squeezed in recent years, but research suggests that healthcare staff who get more workplace learning have higher job satisfaction (Iliopoulous et al., 2018), and training could be one of the best ways to tackle burnout (Dreison et al., 2018).
  5. See if there is a way you can get more time to do aspects of the job you think are important. Carefully consider the parts of your work that give you the greatest sense of satisfaction. Is it building positive relationships with patients? Is it contributing to service level improvements? Is it learning about recent advances in your area and seeking to apply this knowledge to your own patients? Whatever it is, see where there could be scope to spend more time on this. Research suggests that doctors believe having adequate time for key tasks is the most important thing to reduce burnout risk (Fortenberry et al., 2018).

This blog was written in conjunction with a talk given at the Practitioner Wellbeing Conference in Manchester on 14 June 2018. To download a copy of the slides, click here.

Between January 2005 and March 2009, hundreds of patients died due to poor care at Stafford Hospitala. The public enquiry into what had happened at the hospital was launched in November 2010. I was living in nearby Birmingham at the time, and stories of the horrors that had occurred at the hospital were frequently broadcast on the local news. Surgical equipment such as clips and clamps which should have been single-use were being used multiple times; patients on wards were left without water and some became so desperate they drank from vases containing flowers. Food was taken to vulnerable patients but not fed to them, and patients could be heard crying out from their beds due to lack of pain relief.

How could this happen?
As an NHS employee in a neighbouring healthcare trust, I found it hard to fathom how this could have happened. The Francis Report, the final report from the inquiry into Stafford Hospital, was published in February 2013. It suggested the causes were complex. There were significant staff shortages caused by the cutting of jobs in an attempt to meet a £10m budget deficit. When concerns were raised by staff or visitors through relevant forums, these were ignored. Importantly, staff became disengaged at all levels, and this in itself became a hard-to-measure but important cause of suffering.

In one tv news report a former patient, Nicola Monti, describes how she returned to hospital with a bowel condition following the birth of her second baby. She became sicker in the squalid hospital conditions and contracted MRSA. As she speaks about how the nurse communicated this information to her, by throwing the test results down on the bed, tears spring to her eyes. The results meant continued isolation from her two children and intense feelings of loneliness, but it is clear that simply the callous manner in which the nurse told her was in itself a significant cause of pain.

These patterns play out in more muted ways
Staff disengagement had a key role in contributing to the terrible events that occurred in Stafford Hospital. Thankfully the Staffordshire hospital failings are an outlier, but in my experience these patterns can play out in more muted ways. In a service I worked in where bullying was rife and staff were miserable, patient care did not receive the enthusiasm and energy it should have. On the other hand, in services I’ve worked in where staff felt they were part of a functioning and effective team, the mood was more positive and patients received the best that service had to offer.

Time for research
While I had seen these patterns in services I worked in, I wanted to find evidence to back up my anecdote. I arrived in my current job as a Lecturer at the University of Leeds and Bradford Institute for Health Research in October 2013 with this as my focus.

Staff: The greatest asset of the NHS
The first thing I discovered when I began my reading in this area is that the workforce is the greatest asset of the NHS. The NHS is the world’s 5th biggest employer, employing 1.7m staff altogether, including 141,000 doctors and 329,000 nurses, midwives and health visitors. The annual bill for employing clinical staff is £43 billion, which is around half of NHS Trusts’ budgets (National Audit Office, 2016). 

Turnover
The second thing I discovered is the extent to which turnover and sickness absence –clear outcomes of elevated burnout and disengagement – are causing major problems for the NHS. Between 2011 and 2015 the number of staff leaving their jobs each year due to poor work-life balance doubled. Each time a staff member leaves, costs are incurred due to 1) employing temporary staff to fill their role until a replacement is found, 2) advertising, interviewing and recruiting a replacement staff member and 3) training the new staff member. I was unable to find cost estimates for the NHS, but the price of replacing a nurse has been estimated to be $20, 561 in the USA, $26, 652 in Canada, $23, 711 in New Zealand and $48, 790 in Australia (Duffield et al., 2014).

Sickness absence
NHS staff are off work due to sickness for twice the number of days as those working in the private sector. What is particularly concerning is that a significant proportion of these days are due to stress and anxiety. In doctors in acute trusts, 17% of all sickness absence days are in this category; in doctors in mental health trusts it is 26% (see my previous blog for more information on this). These absences can lead to delays and interruptions in care and divert NHS resources to paying for expensive agency cover. This problem is increasing: in 2010, £2.2 billion was spent on agency staff, but by 2015 the figure had risen to £3.3 billion. This leads to a vicious cycle: money that could be spent on enhancing services and supporting existing staff is diverted to agency fees. In turn, services suffer, staff are not as well supported and more leave and become unwell due to stress. This further increases the agency bill, and so on.

Impact on patient care
A large body of evidence shows that higher staff burnout is linked with poorer quality patient care. For example, in a study of emergency doctors published in 2015, those who were classed as suffering from burnout said they more frequently ordered extra tests, failed to treat pain in a timely manner, discharged patients to make the department manageable, did not discuss treatment options or answer patients’ questions, did not communicate important information in handovers and did not discuss treatment plans with appropriate staff (Lu et al., 2015).

This poorer care is reflected in lower patient satisfaction. In an analysis of the NHS staff surveys of 2009, 2010 and 2010 together with trust-level measures, patient satisfaction was higher when fewer staff worked extra hours, more staff felt valued by their colleagues, staff reported lower work pressure and higher levels of engagement (Powell et al., 2014).

The all-important question of patient safety
While there was a lot of research studies on the link between staff engagement, burnout and quality of care indicators, there was much less research on the link with patient safety outcomes. Exploring this was of key importance to me: in Stafford Hospital, patients weren’t just reporting low satisfaction, hundreds had died. Understanding and evidencing the link between staff engagement/burnout and patient safety was paramount to preventing this from happening again. When I told clinical colleagues of my plans, they told me not to bother: “It’s so obvious, of course staff wellbeing and patient safety are linked. You don’t need to research it”. I became slightly concerned I could be wasting my time, but decided to plough on anyway in the hope that like me, someone else might feel the need to evidence the obvious.

First step: A review of the literature
First we undertook the first systematic review of studies linking healthcare staff burnout and wellbeing with patient safety. Forty-six relevant studies were identified. The review found that 89% of the studies which measured wellbeing reported a significant association between wellbeing and patient safety, and 83% that measured burnout reported a significant association between burnout and patient safety. The review was led by Dr Louise Hall and published in PLOS One in 2016, and has since received over 100 citations according to Google Scholar metrics, making me glad that I didn’t heed the initial discouragement I received!

Which matters most – general mental wellbeing or burnout in particular?
The concept of more general mental wellbeing (e.g., depression) is distinct from burnout, which focuses specifically on negative work experiences and attitudes. I became interested in which of these areas may be most important to focus on in relation to patient safety. To address this we conducted a survey study in 323 nurses across 3 trusts. Participants completed measures of burnout, depression and perceptions of patient safety. Statistically speaking, we found that while both burnout and depression had direct individual associations with patient safety perceptions, the association between depression and patient safety was fully mediated by burnout. In other words, we found that depression IS linked with patient safety, but it is the portion of depression that overlaps with burnout that creates this link (See Figure 1). In short, burnout seems to be the more important concept to focus on. We concluded that interventions looking to improve patient safety may benefit from focusing on burnout in particular, for example using strategies to enhance staff engagement in work rather rolling out one-to-one therapy for depression. The study was published in Journal of Advanced Nursing.

Figure 1. It is the portion of depression that overlaps with burnout that is linked with poorer patient safety perceptions.

What are the mechanisms?
A final question we wanted to answer was into the mechanisms of this association: if a staff member is feeling burnt-out, how does this turn into poorer patient care? We addressed this in a qualitative study led by Dr Louise Hall, which was published in the Journal of Patient Safety. Five focus groups with 25 GPs were undertaken. GPs thought poor wellbeing and burnout affects care quality by reducing doctors’ ability to empathize, increasing their negative attitudes to patients and by increasing the likelihood that the GP will simply refer the patient on rather than manage them in clinic, even if the referral isn’t really appropriate. GPs thought that burnout impacts patient safety by reducing their mental functioning and decision making abilities and increasing their fatigue. As one GP said, when burnt-out, they may be less likely to ‘connect dots’ across time and realise that current symptoms may be indicative of a bigger picture indicating a more concerning problem; because of this they could risk missing an important diagnosis.

Interested in how healthcare staff burnout can be tackled? Please see this blog post.

This blog was written in conjunction with a talk given at the Practitioner Wellbeing Conference in Manchester on 14th June 2018. To download a copy of the slides, click here.

a The Francis report of February 2013 concluded that it would be unsafe to infer from these statistics that there was any particular number of avoidable or unnecessary deaths at the trust.