Not all pregnancies follow the textbook. Around 1 in 6 are lost to miscarriage or stillbirth and in 1 in 20 there is an unexpected finding on an ultrasound scan which could suggest the baby has a health condition (Ahman et al., 2014; Blohm et al., 2008; Skupski et al., 1996). Altogether around 150,000 families in England and Wales are affected by one of these complications each year (ONS; 2016). These events are deeply upsetting; parents who experience them are at higher risk for depression, anxiety and even symptoms of trauma (Blackmore et al., 2011; Cumming et al., 2007; Korenromp et al., 2005).

The role of ultrasound

Ultrasound is an important tool for diagnosing these complications and in the UK sonographers are the first to break the news to parents about what they have found. The way this is done is important, as it has a strong emotional impact on expectant parents (Bijma et al., 2008; Johnson et al., 2018). However, there is currently no evidence-based training to support sonographers with news delivery. The training which is available is generally based on research which has been conducted in oncology and other healthcare settings.

The need for an evidence-based training intervention

When I have suggested that new research is needed to understand how bad and difficult news can be better delivered via ultrasound, one question I have been asked is whether this is really needed. Isn’t there plenty of research in other settings to inform training? In this blog, I will present six ways that breaking bad and difficult news via ultrasound is different to breaking bad news in other settings.

1. There is no time for sonographers to prepare before delivering the news

A large body of research tells us that expectant parents study the sonographer’s face as they do the scan: they are attuned to their body language and facial expression and quickly sense when something is wrong. The sonographer is unintentionally communicating news before they even speak, and they have no time alone at all to mentally prepare before sharing what they have found with parents. In cancer care, this would be the same as a doctor having to open test results, read and interpret them while the patient watches them.

2. Having a baby isn’t primarily a healthcare event, it’s a rite of passage

Few people will spend years thinking about their future with a diagnosis of cancer, but many people, consciously or subconsciously, gather quiet expectations about what their future will be like with a child. When you deliver difficult news as a sonographer, you deliver it into a world of positive expectation, which is further fuelled by people sharing scan pictures on social media, and television shows like One Born Every Minute. Because of this, the situation is particularly high stress for both those delivering and those receiving the news.

 3. The need for a second opinion

When a sonographer identifies a miscarriage, stillbirth or fetal anomaly a second opinion is necessary to confirm his. The sonographer needs to leave the scan room to find another qualified healthcare professional who can confirm what has been seen. This is a difficult point, and one that is not encountered in other areas of healthcare. Sonographers are often torn over how much to disclose to the expectant parent before the second opinion has been gathered, especially if they are not confident themselves in what they have seen. Failing to disclose their concerns to the parent can result in parents feeling anxious when they find a second professional has been invited into the scan room without explanation. However, immediately disclosing concerns to parents that are then not confirmed can cause unnecessary anxiety. It’s a dilemma that sonographers regularly face which is not found in other difficult news delivery scenarios.

4. The news may be uncertain

When receiving difficult news in other settings, patients can rightly expect that the healthcare professional telling them this news will be informed about their condition and be able to provide detailed information on this. However, sonographers do not have this luxury. While scanning technology has advanced significantly in the last few decades, it is not always possible to provide accurate diagnoses and prognoses immediately. Because of this, sonographers are often communicating difficult news which is uncertain, and which could change in light of subsequent investigations.

5. Ultrasound presents opportunities and raises challenging choices

Unlike other areas of healthcare, ultrasound often provides a diagnosis before anyone’s health has been compromised. It can enable expectant parents to have missed miscarriages diagnosed and allow them to choose whether they want to shorten the length of their pregnancy by accepting a medical intervention. Ultrasound can also detect some fetal abnormalities.  If a baby is found to have a disability (or a possible disability) parents may need to decide whether to have invasive testing; whether to terminate the pregnancy; or in rare cases, whether to have prenatal interventions. These kinds of decisions introduce a huge weight of responsibility – could prenatal investigations and interventions put the baby or mother at risk? Is it morally wrong to terminate a pregnancy? Will not terminating a pregnancy detract energy from any existing children? When sonographers deliver difficult news they know they are often placing a burden of responsibility on expectant parents to make choices, in a way that is not encountered elsewhere in healthcare.

6. The warning shot is not always wanted

Most models for breaking bad news recommend the delivery of a ‘warning shot’ before the main news is imparted (e.g., Baile et al., 2000). This is designed to prepare patients that bad news is coming, and might run like this: “I’m afraid we have identified some concerning findings in your results”. My research has identified that this warning shot is not always wanted in ultrasound settings because parents have already received their warning shot from the sonographer’s body language and facial expression (see my blog on parent experiences here). These kinds of warning shots only extend the overall duration of the event and serve to increase expectant parents’ anxieties.  Furthermore, if the news being delivered is that the baby has a disability, this kind of warning shot can be taken as a negative value judgement by the healthcare professional, which may offend the expectant parent. Instead, parents prefer to be told things directly but kindly, in simple language. In my previous study in parents of children with limb differences, parents most preferred it when healthcare professionals simply said something like: “I can’t currently see your child’s arm below the elbow” (Johnson et al., 2018).

Summing up

There is strong evidence from other healthcare settings that training to improve news delivery is highly effective (see my blog on this here). However, there are clear differences between breaking bad and difficult news in ultrasound compared with other settings. Assuming that the same principles can be transposed from other healthcare settings into ultrasound without adaptation could at best reduce the effectiveness of training, and at worst, increase parental anxiety.

In 2018, for the first time, the General Medical Council (GMC) included items on burnout in its National Training Survey. The survey was completed by 51,956 trainee doctors and 19,193 trainers, making it the largest burnout survey in UK doctors to date. The response rate was also extremely high – 96% of all doctors in training who were contacted completed it, as did 41% of all contacted trainers. As such, these results provide a reliable picture of the current situation in the medical workforce. The survey found that 24% of trainees and 21% of trainers feel burnt-out to a high degree or a very high degree (for the full report, see here).

When I read these results in the BMJ, I wasn’t surprised. Rates of stress and burnout are high in healthcare staff internationally; in the 2018 Medscape report on physician burnout and depression, out of 15,000 US doctors, 42% were burnt-out and 12% were categorised as ‘colloquially depressed’. I was also concerned: a growing body of research shows a strong and consistent link between higher staff burnout and poorer patient care. Papers I have authored and co-authored show:

• 70% of studies which have investigated burnout and patient safety in healthcare staff have found a significant link between the two (Hall et al., 2016).
• In nurses, higher burnout is linked with poorer perceptions of patient safety both at the level of the individual practitioner and the ward level (Johnson et al., 2017).
• GPs think that burnout affects the quality of patient care by reducing their abilities to emphathise, to show positive attitudes to patients and by increasing the number of inappropriate referrals made (Hall et al., 2017).

Together with Dr Maria Panagioti and Dr Christopher Bu, I decided to respond to the BMJ article on the survey findings to highlight the evidence that burnout in doctors affects patient care. In particular, our letter focused on a recently published systematic review and meta-analysis led by Dr Panagioti. The findings of the review are described in more detail in a previous blog post (see here), but in brief, the review reported that burnt-out doctors are at twice the risk of being involved in a patient safety incident and at twice the risk of having dissatisfied patients.

This research reinforces the importance of measuring burnout in the medical workforce and the need to reduce this. The best way to intervene is currently unclear; while evidence suggests that interventions which target organisations (for example, redesigning jobs) are more effective than those which target individuals (for example, delivering mindfulness courses; Panagioti et al., 2017), there are many interventions which blur this boundary. These include training interventions, which are delivered to individual practitioners but aim to support them in their work, rather than improve their personal coping skills. Evidence suggests these are effective for tackling burnout (Dreison et al., 2018). Clearly, more research is needed. However, while we wait for this, I would suggest that organisations respond to the expressed needs of their workforce, providing the interventions that are both requested and well utilised.

To read our letter to the BMJ, please see here.

To read my previous blog on tackling burnout, please see here.

There is increasing evidence that healthcare staff burnout is linked to a range of negative outcomes, including increased staff absences, higher rate of staff turnover, and poorer quality of patient care (see my previous blog on this here). In a systematic review I co-authored, we found that that 21 out of 30 (70%) studies looking at the link between higher staff burnout and poorer patient safety reported a significant association between the two (Hall et al., 2016). The review found hard evidence for what many clinicians could see happening in their wards and surgeries: when staff are hard pressed, patient care suffers. It was well received on social media and has since been cited dozens of times.

However, while this previous review found clear evidence for a link between staff burnout and patient safety, it seemed to me that two questions remained unanswered. The first was whether there is also a link between burnout and other aspects of patient care, such as patient satisfaction. The second was what the strength of this relationship is: that is, just how much do increases in burnout impact patient care?

So, when I was invited to contribute to a systematic review on the links between burnout and patient care in doctors by Dr Maria Panagioti, I jumped at the chance. The review led by Dr Panagioti aimed to answer both these questions. It gathered studies which investigated burnout in doctors in relation to a broader range of outcomes, including:

  1. Patient safety incidents, (e.g., adverse events, medication errors, diagnostic incidents)
  2. Low professionalism (e.g., adherence to treatment guidelines, quality of communication, malpractice claims, empathy)
  3. Low patient satisfaction

It also quantified the strength of these relationships using meta-analysis, which was not employed in the previous review.

Is burnout linked with patient safety incidents?

The review identified 21 studies which reported on the association between burnout and patient safety incidents. The results of the meta-analyses suggested that burnt-out doctors were twice as likely to be involved in a patient safety incident as those not suffering from burnout. All aspects of burnout (exhaustion, disengagement and low accomplishment) were associated with a significantly higher risk of being involved in a patient safety incident.

Is burnout linked with low professionalism?

28 studies were found which reported on the link between burnout and low professionalism (e.g., showing low empathy, having received a malpractice claim). The results of the meta-analyses suggested that burnt-out doctors were twice as likely to show low professionalism. When the different aspects of burnout were examined separately, disengagement was the aspect most linked with low professionalism. Doctors who were disengaged from their patients were 3-times as likely to exhibit low professionalism. Doctors high in emotional exhaustion or low in personal accomplishment were over 2.5-times as likely to exhibit low professionalism.

Importantly, the review found that the link between burnout and low professionalism was twice as high in trainee and early career doctors compared with more experienced doctors. This is particularly concerning when the recent GMC survey results showing that a quarter of trainee doctors are burnt-out are considered.

Is burnout linked with low patient satisfaction?

7 studies reported measures of patient satisfaction. It was found that burnt-out doctors were at twice the risk of having dissatisfied patients. Again, disengagement was the aspect of burnout most closely linked with low patient satisfaction, with disengaged doctors showing a 4.5-fold increased risk. Low personal accomplishment was also linked with twice the risk of low patient satisfaction. No link was found with emotional exhaustion.

Where now?

This review finds strong evidence that burnt-out doctors are at significantly higher risk of being involved in patient safety incidents, showing low professionalism and having dissatisfied patients. Having clarified the presence and size of the problem of burnout for patient care, the next step for us as researchers is to identify evidence-based solutions to this problem. While a number of interventions to reduce burnout have been proposed (see Panagioti et al., 2017), there is a need to identify 1) which interventions are most feasible and most effective, and 2) whether reducing burnout can improve patient care.

For my previous blog on tackling burnout, please see here.

The review described in this article was published in JAMA: Internal Medicine. To read it, please 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.