Grace Under Pressure: a mixed methods impact assessment of a verbatim theatre intervention to improve healthcare workplace culture.

BACKGROUND: Healthcare workplace mistreatment has been documented globally. Poor workplace behaviour, ranging from incivility to bullying and harassment, is common in healthcare, and contributes significantly to adverse events in healthcare, poor mental health among healthcare workers, and to attrition in the healthcare workforce, particularly in junior years. Poor workplace behaviour is often normalised, and is difficult to address. Verbatim theatre, a form of research informed theatre in which plays are created from informants' exact words only, is particularly suited to facilitating workplace culture change by raising awareness about issues that are difficult to discuss. The objective of this study was to assess the impact of the verbatim theatre play 'Grace Under Pressure' on workplace culture in NSW hospitals. METHODS: The intervention was conducted in 13 hospitals from 8 Local Health Districts (LHDs) in NSW, Australia, in October and November 2019, with aggregated impact across all sites measured by a bespoke survey ('Pam McLean Centre (PMC) survey') at the conclusion of the intervention. This study was conducted in 3 Local Health Districts (one urban, one regional, one remote), with data collection conducted in November-December 2019 and December 2020. The study design was a mixed methods assessment of the play's impact using (1) validated baseline measures of psychosocial risk, analysed descriptively, (2) overall findings from the PMC survey above, analysed descriptively, (3) interviews conducted within a month of the intervention, analysed thematically and (4) interviews conducted one year later, analysed thematically. RESULTS: Half (51.5%) of the respondents (n = 149) to the baseline survey had scores indicating high risk of job strain and depressive symptoms. Of 478 respondents to the PMC survey (response rate 57%), 93% found the play important, 92% recommended others see the play, 89% considered that it stimulated thinking about workplace behaviour, and 85% that it made discussing these issues easier. Thematic analysis of interviews within one month (n = 21) showed that the play raised awareness about poor workplace behaviour and motivated behaviour change. Interviews conducted one year later (n = 6) attributed improved workplace culture to the intervention due to improved awareness, discussion and capacity to respond to challenging issues. CONCLUSIONS: Verbatim theatre is effective in raising awareness about difficult workplace behaviour in ways that motivate behaviour change, and hence can be effective in catalysing real improvements in healthcare workplace culture. Creative approaches are recommended for addressing similarly complex challenges in healthcare workforce retention.

How peer review groups support learning and wellbeing in psychiatrists.

OBJECTIVE: To explore the self-reported value of Peer Review Groups (PRGs) by Australian psychiatrists, focussing on learning and wellbeing. METHODS: A cross-sectional mixed-methods online survey of psychiatrists registered with the NSW Branch Royal Australian and New Zealand College of Psychiatrists (RANZCP) who had attended a PRG in the previous 12 months. RESULTS: Respondents described PRG participation as supportive to their learning and to their professional wellbeing by sharing professional experiences, emotional support for the inherent stresses of practice, the provision of a space for debriefing and the amelioration of professional isolation. Difficulties or challenges in group functioning were reported rarely and included new group member selection and limitations to individual support provided by the group. CONCLUSIONS: The PRG form of Continuing Professional Development (CPD) is unique, popular and highly valued by psychiatrists. In addition to supporting learning, PRGs provide a collegial space for processing of emotional aspects of practice that in turn supports wellbeing. Other healthcare professionals might benefit from similar self-directed, self-selected small group peer contact for CPD.

Transforming the journey together: Baseline findings from a longitudinal, co-designed study on psychiatry trainee experiences of training and wellbeing.

OBJECTIVE: Junior doctors have high rates of burnout resulting in downstream impacts on patient care. The aim of this study is to capture cross-sectional data on a cohort of psychiatry trainees. These data will be used to inform a wider project investigating psychiatry trainee mental health and wellbeing. METHOD: This paper reports on the 2019 baseline data of psychiatry trainees enrolled in a formal education course at the University of Sydney, Australia. The data were collected with an online survey using a range of validated mental health and wellbeing scales. This descriptive study involved psychiatry trainees as co-designers. RESULTS: Our research findings are in keeping with the existing literature on the poor mental health and wellbeing of doctors with significantly higher levels of anxiety and exhaustion found in female trainees and carers. Despite this, the cohort had high scores on the flourishing scale. CONCLUSIONS: Concern around the wellbeing of junior doctors in Australia appears justified. We need to move beyond focussing on individual action to systems-based approaches to improving wellbeing and ongoing sustainability of the psychiatry trainee workforce in NSW.

Should we be Royal?

OBJECTIVE: Our college name The Royal Australian and New Zealand College of Psychiatrists (RANZCP) and Crest (Coat of Arms) are echoes of our colonial past, which create a barrier to an inclusive 21st-century Australasian psychiatry. Two hundred and fifty years after European settlement, this article reviews the colonial legacy, the evolution of the college and the process by which the prefix 'Royal' came to be attached. This is now an anachronism that symbolically undermines our mission to create a fully inclusive psychiatry for all Australians and New Zealanders, from indigenous people across the spectrum of cultures drawn from recent migrations within our complex multicultural society. CONCLUSION: As psychiatrists, it is time to modernise and reinvent the college name and Crest. We will be a healthier and more inclusive community of practice without the 'Royal' prefix, and with a new symbol for our college that embodies our values and vision.

Verbatim Theater: Prompting Reflection and Discussion about Healthcare Culture as a Means of Promoting Culture Change.

Problem: The mistreatment of medical and nursing students and junior health professionals has been reported internationally in research and the media. Mistreatment can be embedded and normalized in hierarchical healthcare workplaces, limiting the effectiveness of policies and reporting tools to generate change; as a result, some of those who experience mistreatment later perpetuate it. We used a novel, creative approach, verbatim theater, to highlight the complexity of healthcare workplaces, encourage critical reflection, and support long-term culture change. Intervention: Verbatim theater is a theater-for-change documentary genre in which a playscript is devised using only the words spoken by informants. In 2017, 30 healthcare students and health professionals were recruited and interviewed about their experience of work and training by the multidisciplinary Sydney Arts and Health Collective using semi-structured interviews. Interview transcripts became the primary material from which the script for the verbatim theater play 'Grace Under Pressure' was developed. The performing arts have previously been used to develop the communication skills of health professional students; this esthetic expression of the real-life effects of healthcare workplace culture on trainees and students was implemented to stimulate consciousness of, and dialogue about, workplace mistreatment in healthcare work and training. Context: The play premiered at a major Sydney theater in October 2017, attended by the lay public and student and practicing health professionals. In November 2017, three focus groups were held with a sample of audience members comprising healthcare professionals and students. These focus groups explored the impact of the play on reflection and discussion of healthcare culture and/or promoting culture change in the health workplace. We analyzed the focus group data using theoretical thematic analysis, informed by Turner's theory of the relation between 'social' and 'esthetic' drama to understand the impact of the play on its audience. Impact: Focus group members recognized aspects of their personal experience of professionalism, training, and workplace culture in the play, Grace Under Pressure. They reported that the play's use of real-life stories and authentic language facilitated their critical reflection. Participants constructed some learning as 'revelation,' in which the play enabled them to gain significant new insight into the culture of health care and opened up discussions with colleagues. As a result, participants suggested possible remedies for unhealthy aspects of the culture, including systemic issues of bullying and harassment. A small number of participants critiqued aspects of the play they believed did not adequately reflect their experience, with some believing that the play over-emphasized workplace mistreatment. Lessons Learned: Verbatim theater is a potent method for making personal experiences of healthcare workplace and training culture more visible to lay and health professional audiences. In line with Turner's theory, the play's use of real-life stories and authentic language enabled recognition of systemic challenges in healthcare workplaces by training and practicing health professionals in the audience. Verbatim theater provides a means to promote awareness and discussion of difficult social issues and potential means of addressing them.

Career medical officers in psychiatry and addiction in NSW: description, role and educational needs.

OBJECTIVE: To describe the workforce of career medical officers (CMOs) working in psychiatry and addiction medicine across New South Wales (NSW) and to explore their training and education needs, and experience of their role. METHOD: A cross-sectional survey of CMOs in NSW working in psychiatry or addiction medicine. The survey consisted of quantitative data and free-text responses, and was conducted online in late 2017. RESULTS: Of the 41 CMOs identified and sent the survey link, 25 CMOs completed the survey (61% RR). Almost half had worked as a CMO for 11 years or longer. Only six respondents held a recognised senior CMO position. Common areas of expertise were clozapine, metabolic health, and electroconvulsive therapy (ECT). One-quarter of respondents did not receive supervision. Suggested education and training improvements included an annual 1-day training symposium and monthly peer review group for CMOs. CONCLUSION: CMOs are an often senior group of clinicians working in important areas of service provision. Ongoing educational support for this group of medical practitioners is prudent to ensure the delivery of best practice mental health and drug health care.

Where do Peer Review Groups fit in the international Continuing Professional Development literature?

OBJECTIVES: To describe what is reported in the Continuing Professional Development (CPD) literature on small group learning formats in medicine, including the Royal Australian and New Zealand College of Psychiatrists (RANZCP) CPD Peer Review Groups (PRGs). METHOD: A literature review of international peer-reviewed publications in relation to the use of small group learning formats for CPD in medicine. RESULTS: Small groups are commonly used as a learning format in medical CPD, primarily in general practice, but are little researched. Such groups take differing forms and they are valued by participants for a range of purposes, having effects on professionalism, clinical performance and doctors' wellbeing. CONCLUSION: We believe that the contribution of these groups to medical CPD should be further explored. To this end, this review forms the first part of a research project focussing on the RANZCP PRG model used by Australian and New Zealand psychiatrists.

Burnout and distress in Australian physician trainees: Evaluation of a wellbeing workshop.

OBJECTIVE: To evaluate the effectiveness of a workshop intervention to promote wellbeing for Australian physician trainees using a randomized-controlled design. METHODS: Participants were randomly assigned into intervention and control groups. The intervention group attended a half-day workshop. Outcome measures included depression anxiety stress scale, professional quality of life scale and alcohol use disorders identification test. Demographic and work/life factors were measured. Measurements were recorded at baseline, 3 and 6 months, and the workshop was evaluated by participants. RESULTS: High rates of burnout (76%) and secondary traumatic stress (91%) were detected among study participants and around half met screening criteria for depression (52%), anxiety (46%) and stress (50%) at baseline. Workshop evaluations showed that participants agreed that the training was relevant to their needs (96%) and met their expectations (92%). There was a small reduction in alcohol use, depression and burnout in the intervention group compared with the control group at 6 months, but these changes did not reach statistical significance. CONCLUSION: High rates of psychological morbidity detected in the study suggest that physician trainees are a vulnerable group who may benefit from initiatives that promote wellbeing and changes in the workplace to reduce distress.

Nutritional strategies to reduce falls risk in older people.

A literature review found an association between increased falls risk and malnutrition, sarcopenia, vitamin D deficiency and dehydration. Strategies to identify, prevent and treat these conditions can help to reduce falls risk in at-risk groups such as frail, older people. Nurses can reduce falls risk in older people by raising awareness of risk factors and embedding nutritional strategies in local falls reduction strategies.

Incorporating active learning in psychiatry education.

OBJECTIVE: We aim to summarise the active learning literature in higher education and consider its relevance for postgraduate psychiatry trainees, to inform the development of a new Formal Education Course (FEC): the Master of Medicine (Psychiatry) at the University of Sydney. METHOD: We undertook a literature search on 'active learning', 'flipped classroom', 'problem-based learning' and 'psychiatry education'. RESULTS: The effectiveness of active learning pedagogy in higher education is well supported by evidence; however, there have been few psychiatry-specific studies. A new 'flipped classroom' format was developed for the Master of Medicine (Psychiatry). CONCLUSIONS: Postgraduate psychiatry training is an active learning environment; the pedagogical approach to FECs requires further evaluation.

Grace Under Pressure: a drama-based approach to tackling mistreatment of medical students.

A positive and respectful learning environment is fundamental to the development of professional identities in healthcare. Yet medical students report poor behaviour from healthcare professionals that contradict professionalism teaching. An interdisciplinary group designed and implemented a drama-based workshop series, based on applied theatre techniques, to help students develop positive professional qualities and interpersonal skills to deal with challenges in the healthcare setting. We piloted the workshops at the University of Sydney in 2015. Attendees completed evaluation questionnaires and participated in a focus group or interview. Of 30 workshop attendances, there were 29 completed questionnaires and three participants attended a focus group or interview. Workshop activities were rated as 'very good' or 'good' by 21/22 (95.5%). Thematic analysis of qualitative data highlighted the rationale for participation (to deal with bullying, prevent becoming a bully, learn social skills), workshop benefits (express emotions, learn about status dynamics and deconstructing personalities, empathy, fun), challenges (meeting participants' expectations, participants' need for further practice) and implications for medical education (need to develop awareness of others' perspectives). Our research has shown that there is momentum to challenge mistreatment in medical education. While a multipronged approach is needed to generate systemic change, this pilot offers a positive and creative innovation. It helps students improve their interpersonal skills and sense of self to deal with challenges in the healthcare setting, including mistreatment.

Psychiatry training experiences: a narrative synthesis.

OBJECTIVE: In Australia and internationally, psychiatry has struggled to fill training places to keep up with demand for service. The objective of this study was to review the components of psychiatry terms and placements that determine a positive experience and potentially influence interest in vocational training in psychiatry. METHOD: A literature review and narrative synthesis was undertaken on 20 papers identified as meeting inclusion criteria. RESULTS: The top themes contributing to positive experiences during the psychiatry term were: receiving high quality supervision; supported autonomy; and witnessing patient recovery. There was a paucity of Australian literature preventing investigation of the Australian context alone. CONCLUSIONS: There is a need to better understand how the junior doctor and medical student psychiatry experience influences perceptions of psychiatry and intention to specialise, especially in the Australian context.

Psychiatry trainees confidence as teachers, perceptions of supervisor support and opportunities for further training.

OBJECTIVE: To investigate psychiatry trainees' confidence in their role as teachers, their perceptions of support and preferences for a program to support this role. METHODS: Psychiatry trainees in New South Wales (NSW) (Australia) in the first three years of psychiatry training (N = 118) were invited to complete a survey which included demographic data, self-assessment of teaching confidence and perceptions of support for teaching. RESULTS: A total of 63% (N = 74) agreed to participate. Overall, 62% percent of participants regarded teaching as an important part of their role, 46% felt supported in the role by their training supervisors, but only 18% regularly discussed their teaching role in routine supervision. CONCLUSIONS: Psychiatry trainees viewed teaching as part of their role. They reported a low level of formal training in teaching skills and perceived a low level of support from supervisors. Registrar training needs to address trainees' competencies in a range of teaching skills along with supervisor support. Further research is required to assess the impact of a teaching program on teaching performance and learner outcomes.

The experience of psychiatry training in rural NSW.

OBJECTIVE: To examine the experience of psychiatry training in rural New South Wales. METHOD: All rural trainees in New South Wales and key psychiatrists involved in their training were invited to complete a survey in May-July 2013. RESULTS: Responses were received from 26 out of 44 rurally placed psychiatry trainees (57% response rate) and 37 out of 55 psychiatrists involved in training in a rural area (67% response rate). Positive and negative aspects of rural training were reported. In general, trainees reported positive experiences regarding supervision, consultant input and their Site Coordinator of training. Their experience of other aspects of training and education in rural areas was often negative with 52% of trainees feeling at a disadvantage due to fewer registrar peers and 60% feeling educationally isolated. Difficulty progressing through training, workforce shortages, difficulty accessing formal aspects of training and limited options for advanced training were reported. Metropolitan trainees on rotation to rural terms receive accommodation, travel and an increase in wage from the rural Local Health District. Rural trainees on rotation to the city for their mandatory subspecialty training receive no such support. CONCLUSIONS: There are many challenges for rural trainees. Support from the Royal Australian and New Zealand College of Psychiatrists and state and federal governments to enhance the rural training experience is vital.

Mandatory reporting of health professionals: the case for a Western Australian style exemption for all Australian practitioners.

This article discusses the current mandatory reporting obligations for health practitioners in Australia under the Health Practitioner Regulation National Law. It provides a summary of the mandatory notification legislation, and contextualises the introduction of this law. The details of the Western Australian exemption, under which a treating doctor is exempt from mandatory reporting of a doctor-patient, and the rationale for its introduction are examined. This is followed by a consideration of the potential impact of the mandatory reporting obligations. The authors argue that the Western Australian exemption has merit and should be considered for adoption throughout Australia.

The role of trainees as clinical teachers of medical students in psychiatry.

OBJECTIVE: To consider the role of specialty trainees as clinical teachers of medical students in psychiatry. METHOD: We discuss the role of specialty trainees as teachers and approaches to improving their skills and capacity, giving examples from the local and international literature and our own experience as psychiatry medical educators. RESULTS: Good clinical teaching is crucial for medical students' learning but sharp increases in numbers combined with economic and workforce pressures have stretched capacity. Specialty trainees do much of the medical student teaching during their clinical placements but infrequently receive instruction on how to teach. The two common approaches to increasing capacity are, first, establishing education rotations for individual trainees and, second, providing workshops to improve trainees' confidence and skill. Psychiatry trainees surveyed in New South Wales welcomed the role of teacher and the opportunity to improve their teaching capacity. Further support from supervisors, health services and medical schools is needed to assist trainees in their teaching role. CONCLUSION: The role that trainees play as clinical teachers should be acknowledged and supported. Further development of research and scholarship in medical education is needed to determine how best to teach trainees to teach.

Work, boredom and rhythm in the time of COVID-19.

This article uses Henri Lefebvre's Rhythmanalysis as a foundational text for researching boredom, and offers a critical analysis of UK-based media commentaries about boredom and homeworking written during 2020 and 2021. We situate the discussion within the rhythmic rupture caused by the COVID-19 pandemic and foreground rhythm as a lens for understanding reported experiences and reflections on boredom and work. For non-essential workers, lockdown offered an opportunity to reconfigure working lives away from the constraints of commutes and everyday work settings, yet our findings highlight the narrative representation and experience of a particular type of boredom and inertia known as acedia. The analysis discusses the presence of acedia and absence of rhythm across three themes: acedia and being stuck in time and space; embodiment, movement and rhythm; and the relationship between the present and the future. We conclude by considering what the experience of boredom might mean for how we reconceptualise our post-pandemic working lives.

How to assess pain in children and young people.

Emergency nurse practitioners often experienced difficulties when attempting to assess pain in children accurately. This article refers to a case study to discuss the complexities of measuring paediatric pain, reviews two of the most well-known pain assessment scales and emphasises the importance of family involvement in situations where children are asked to self-report their experiences.

Bridging the gap: A new integrated early intervention service for young people with complex mental health issues.

AIM: Two integrated headspace Early Intervention Teams (hEITs) were established in 2017 to bridge gaps between headspace, the national primary care youth mental health programme in Australia, and the state funded secondary and tertiary mental health services. This study aims to describe functioning and outcomes of patients referred to hEIT over a 6-month period. METHODS: A retrospective file audit was conducted for all patients accepted into the service over a 6-month period in 2018. Measures of distress, functioning and client satisfaction were collected and analysed. Exemplar vignettes were created to construct hypothetical examples and illustrate research findings. RESULTS: At admission, the three most common presentations were depression/anxiety, trauma and stress related, and psychotic disorders. During their time in the service, young people displayed a statistically significant improvement in functioning, reduction in self-harm in those 18 years and under, and a trend to reduction in distress scores. hEIT delivered a broad range of services covering social, occupational, educational, medical and mental health care, and the service was experienced positively by the patient cohort. CONCLUSIONS: hEIT appears to meet the needs of young people requiring greater care than primary care services can deliver. The integrated, wrap-around care coordination facilitates treatments across social, educational and health domains. Further exploration of young people who disengage from care, improved outcome data reporting and economic evaluation are indicated.