Causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics: the Care Under Pressure 2 realist review.

Background: Nurses, midwives and paramedics are the largest collective group of clinical staff in the National Health Service and have some of the highest prevalence of psychological ill-health. Existing literature tends to be profession-specific and focused on individual interventions that place responsibility for good psychological health with nurses, midwives and paramedics themselves. Aim: To improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related psychological ill-health; and determine which high-quality interventions can be implemented to minimise psychological ill-health in these professions. Methods: Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards' reporting guidelines. Data sources: First round database searching in Medical Literature Analysis and Retrieval System Online Database ALL (via Ovid), cumulative index to nursing and allied health literature database (via EBSCO) and health management information consortium database (via Ovid), was undertaken between February and March 2021, followed by supplementary searching strategies (e.g. hand searching, expert solicitation of key papers). Reverse chronology screening was applied, aimed at retaining 30 relevant papers in each profession. Round two database searches (December 2021) targeted COVID-19-specific literature and literature reviews. No date limits were applied. Results: We built on seven key reports and included 75 papers in the first round (26 nursing, 26 midwifery, 23 paramedic) plus 44 expert solicitation papers, 29 literature reviews and 49 COVID-19 focused articles in the second round. Through the realist synthesis we surfaced 14 key tensions in the literature and identified five key findings, supported by 26 context mechanism and outcome configurations. The key findings identified the following: (1) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; (2) it is difficult to promote staff psychological wellness where there is a blame culture; (3) the needs of the system often override staff well-being at work ('serve and sacrifice'); (4) there are unintended personal costs of upholding and implementing values at work; and (5) it is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors. Conclusions: Our realist synthesis strongly suggests the need to improve the systemic working conditions and the working lives of nurses, midwives and paramedics to improve their psychological well-being. Individual, one-off psychological interventions are unlikely to succeed alone. Psychological ill-health is highly prevalent in these staff groups (and can be chronic and cumulative as well as acute) and should be anticipated and prepared for, indeed normalised and expected. Healthcare organisations need to (1) rebalance the working environment to enable healthcare professionals to recover and thrive; (2) invest in multi-level system approaches to promote staff psychological well-being; and use an organisational diagnostic framework, such as the NHS England and NHS Improvement Health and Wellbeing framework, to self-assess and implement a systems approach to staff well-being. Future work: Future research should implement, refine and evaluate systemic interventional strategies. Interventions and evaluations should be co-designed with front-line staff and staff experts by experience, and tailored where possible to local, organisational and workforce needs. Limitations: The literature was not equivalent in size and quality across the three professions and we did not carry out citation searches using hand searching and stakeholder/expert suggestions to augment our sample. Study registration: This study is registered as PROSPERO CRD42020172420. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172420. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129528) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 9. See the NIHR Funding and Awards website for further award information.

The National Health Service needs healthy, motivated staff to provide high-quality patient care. Nurses, midwives and paramedics experience poor psychological health (e.g. stress/anxiety) because of pressured environments and the difficulties of healthcare work. This study planned to better understand the causes of poor psychological ill-health in nurses, midwives and paramedics and find which interventions might help and why. We analysed the literature using a method called 'realist review' to understand how interventions work (or not), why, and for who. We tested our findings with patients, the public, nurses, midwives and paramedics in our stakeholder group. We reviewed over 200 papers/reports and identified five main findings: (1) existing solutions (interventions) are disjointed, focus mainly on the individual (not the system) and do not recognise enduring stressors enough; (2) when there is a blame culture it is difficult to encourage staff psychological well-being; (3) the needs of the system often override staff psychological well-being at work; (4) upholding and implementing personal and professional values at work can have negative personal costs; and (5) it is difficult to design, identify and implement solutions that work well for staff groups in different circumstances with varied causes of poor psychological health. Healthcare organisations should consider: (1) changing (rebalancing) the working environment to help healthcare professionals rest, recover and thrive; (2) investing in multiple-level system (not just individual) approaches to staff psychological well-being; (3) continuing to reduce stigma; (4) ensuring the essential needs of staff are prioritised (rest-breaks/hydration/hot food) as building blocks for other solutions; (5) addressing the blame culture, assuming staff are doing their best in difficult conditions; (6) prioritising staff needs, as well as patient needs. We will provide guidance and recommendations to policy-makers and organisational leaders to improve work cultures that tackle psychological ill-health and suggest new areas for research.

Coping with COVID-19. Work life experiences of nursing, midwifery and paramedic academics: An international interview study.

BACKGROUND: The COVID-19 global pandemic was declared in March 2020. By June 2022, the total deaths worldwide attributed to COVID-19 numbered over 6.3 million. Health professionals have been significantly impacted worldwide primarily those working on the frontline but also those working in other areas including nursing, midwifery, and paramedic higher education. Studies of occupational stress have focused on the clinical health professional roles but scant attention has been drawn to the pressures on university-based academic staff supporting and preparing professionals for frontline health work. DESIGN AND OBJECTIVES: This qualitative study sought to explore the challenges experienced by health academics (nurses, midwives and paramedics), during COVID-19 and identify strategies enlisted. SETTING AND PARTICIPANTS: Six Australian and two United Kingdom universities collaborated, from which 34 health academics were individually interviewed via video or teleconference, using six broad questions. Ethical approval was obtained from the lead site and each participating University. DATA ANALYSIS: Thematic analysis of the data was employed collaboratively across institutions, using Braun and Clarke's method. RESULTS: Data analysis generated four major themes describing academics': Experiences of change; perceptions of organisational responses; professional and personal impacts; and strategies to support wellbeing. Stress, anxiety and uncertainty of working from home and teaching in a different way were reported. Strategies included setting workday routine, establishing physical boundaries for home-working and regular online contact with colleagues. CONCLUSIONS: The ability of nursing, midwifery and, paramedic academic staff to adapt to a sudden increase in workload, change in teaching practices and technology, while being removed from their work environment, and collegial, academic and technological supports is highlighted. It was recognised that these changes will continue post-COVID and that the way academics deliver education is forever altered.

'The WOW factors': comparing workforce organization and well-being for doctors, nurses, midwives and paramedics in England.

BACKGROUND: High rates of poor mental health in healthcare staff threatens the quality and sustainability of healthcare delivery. Multi-factorial causes include the nature and structure of work. We conducted a critical review of UK NHS (England) data pertaining to: doctors, nurses, midwives and paramedics. SOURCES OF DATA: Key demographic, service architecture (structural features of work) and well-being indicators were identified and reviewed by a stakeholder group. Data searching prioritized NHS whole workforce sources (focusing on hospital and community health services staff), which were rated according to strength of evidence. FINDINGS: Key differences between professions were: (i) demographics: gender (nursing and midwifery female-dominated, doctors and paramedics more balanced); age (professions other than doctors had ageing workforces); ethnicity (greater diversity among doctors and nurses); (ii) service architecture: despite net staffing growth, turnover and retention were problematic in all professions; 41.5% doctors were consultants but smaller proportions held high grade/band roles in other professions; salaries were higher for doctors; (iii) well-being: all reported high job stress, particularly midwives and paramedics; sickness absence rates for nurses, midwives and paramedics were three times those of doctors, and presenteeism nearly double. GROWING POINTS: Sociocultural factors known to increase risk of poor mental health may explain some of the differences reported between professions. These factors and differences in service architecture are vital considerations when designing strategies to improve well-being. AREAS TIMELY FOR DEVELOPING RESEARCH: Multi-level systems approaches to well-being are required that consider intersectionality and structural differences between professions; together with inter-professional national databases to facilitate monitoring.

The impact of COVID-19 on the wellbeing of the UK nursing and midwifery workforce during the first pandemic wave: A longitudinal survey study.

BACKGROUND: The specific challenges experienced by the nursing and midwifery workforce in previous pandemics have exacerbated pre-existing professional and personal challenges, and triggered new issues. We aimed to determine the psychological impact of the COVID-19 pandemic on the UK nursing and midwifery workforce and identify potential factors associated with signs of post-traumatic stress disorder. METHODS: A United Kingdom national online survey was conducted at three time-points during the first wave of the COVID-19 pandemic between April and August 2020 (T1 and T2 during initial wave; T3 at three-months following the first wave). All members of the UK registered and unregistered nursing and midwifery workforce were eligible to participate. The survey was promoted via social media and through organisational email and newsletters. The primary outcome was an Impact of Events Scale-Revised score indicative of a post-traumatic stress disorder diagnosis (defined using the cut-off score ≥33). Multivariable logistic regression modelling was used to assess the association between explanatory variables and post-traumatic stress disorder. RESULTS: We received 7840 eligible responses (T1- 2040; T2- 3638; T3- 2162). Overall, 91.6% participants were female, 77.2% were adult registered nurses, and 28.7% were redeployed during the pandemic. An Impact of Events Scale-Revised score ≥33 (probable post-traumatic stress disorder) was observed in 44.6%, 37.1%, and 29.3% participants at T1, T2, and T3 respectively. At all three time-points, both personal and workplace factors were associated with probable post-traumatic stress disorder, although some specific associations changed over the course of the pandemic. Increased age was associated with reduced probable post-traumatic stress disorder at T1 and T2 (e.g. 41-50 years at T1 odds ratio (OR) 0.60, 95% confidence interval (CI) 0.42-0.86), but not at T3. Similarly, redeployment with inadequate/ no training was associated with increased probable post-traumatic stress disorder at T1 and T2, but not at T3 (T1 OR 1.37, 95% CI 1.06-1.77; T3 OR 1.17, 95% CI 0.89-1.55). A lack of confidence in infection prevention and control training was associated with increased probable post-traumatic stress disorder at all three time-points (e.g. T1 OR 1.48, 95% CI 1.11-1.97). CONCLUSION: A negative psychological impact was evident 3-months following the first wave of the pandemic. Both personal and workplace are associated with adverse psychological effects linked to the COVID-19 pandemic. These findings will inform how healthcare organisations should respond to staff wellbeing needs both during the current pandemic, and in planning for future pandemics.

Improving fatigue risk management in healthcare: A scoping review of sleep-related/ fatigue-management interventions for nurses and midwives (reprint).

BACKGROUND: Nurses and midwives make up almost 50% of the global healthcare shift working workforce. Shift work interferes with sleep and causes fatigue with adverse effects for nurses' and midwives' health, as well as on patient safety and care. Where other safety-critical sectors have developed Fatigue Risk Management Systems, healthcare is behind the curve; with published literature only focussing on the evaluation of discreet sleep-related/fatigue-management interventions. Little is known, however, about which interventions have been evaluated for nurses and midwives. Our review is a critical first step to building the evidence-base for healthcare organisations seeking to address this important operational issue. OBJECTIVES: We address two questions: (1) what sleep-related/fatigue-management interventions have been assessed in nurses and midwives and what is their evidence-base? and (2) what measures are used by researchers to assess intervention effectiveness? DESIGN AND DATA SOURCES: The following databases were searched in November, 2018 with no limit on publication dates: MEDLINE, PsychINFO and CINAHL. REVIEW METHODS: We included: (1) studies conducted in adult samples of nurses and/or midwives that had evaluated a sleep-related/fatigue-management intervention; and (2) studies that reported intervention effects on fatigue, sleep, or performance at work, and on measures of attention or cognitive performance (as they relate to the impact of shift working on patient safety/care). RESULTS: The search identified 798 potentially relevant articles, out of which 32 met our inclusion criteria. There were 8619 participants across the included studies and all were nurses (88.6% female). We did not find any studies conducted in midwives nor any studies conducted in the UK, with most studies conducted in the US, Italy and Taiwan. There was heterogeneity both in terms of the interventions evaluated and the measures used to assess effectiveness. Napping could be beneficial but there was wide variation regarding nap duration and timing, and we need to understand more about barriers to implementation. Longer shifts, shift patterns including nights, and inadequate recovery time between shifts (quick returns) were associated with poorer sleep, increased sleepiness and increased levels of fatigue. Light exposure and/or light attenuation interventions showed promise but the literature was dominated by small, potentially unrepresentative samples. CONCLUSIONS: The literature related to sleep-related/fatigue-management interventions for nurses and midwives is fragmented and lacks cohesion. Further empirical work is warranted with a view to developing comprehensive Fatigue Risk Management Systems to protect against fatigue in nurses, midwives, and other shift working healthcare staff.

The adoption of person-centred care in chiropractic practice and its effect on non-specific spinal pain: An observational study.

OBJECTIVES: The objectives of this study were to identify: 1) the extent to which final year chiropractic students used components of person-centred care in a clinical setting; and 2) determine the effect of chiropractic students' use of person-centred care on musculoskeletal pain. DESIGN/SETTING: An observational study was conducted at three Western Australian chiropractic teaching clinics. INTERVENTIONS: Pragmatic individualised chiropractic care was delivered to 108 adults who experienced non-specific spinal pain. MAIN OUTCOME MEASURES: The instruments used in this study were the Consultation and Relational Empathy questionnaire, Picker Musculoskeletal Disorder Questionnaire, and Numerical Rating scale for Pain intensity. RESULTS: Participants experienced reductions in pain that exceeded the level required for minimal clinically reported improvement. In addition, high levels of empathy and patient -centred care were reported. Ceiling effects for the measures assessing empathy and patient-centred care precluded analyses examining the relationship between changes in pain intensity, empathy, and patient-centred care. CONCLUSIONS: The participants in this study displayed very positive attitudes about most aspects of the chiropractic students' person-centred care skills. Person-centred care processes for which there was considerable scope for improvement included advice about alternative treatment options, and the adaptation of lifestyle and workplace situations to alleviate pain and enhance health. Our findings also showed that the participants experienced clinically important improvement in pain. However, the skewed nature of our dataset precluded identifying whether the students' person-centred care skills influenced such improvement.

'Catching up': The significance of occupational communities for the delivery of high quality home care by community nurses.

This article examines the importance of some informal work practices among community nurses during a period of significant organizational change. Ethnographic fieldwork in two purposively selected adult community nursing services in England comprised 79 hours of observation of routine practice, 21 interviews with staff and 23 interviews with patients. We identified the informal work practice of 'catching up', informal work conversations between immediate colleagues, as an important but often invisible aspect of satisfying work relationships and of the relational care of patients. Drawing on anthropological literatures on 'communities of practice' the article examines two central issues concerning the practices of 'catching up': (1) how informal learning processes shape community nursing work; (2) how this informal learning is shaped both in relation to the ideals of community nursing work and the wider political and organizational contexts of community nursing practice. Our findings highlight the distinctive value of informal workplace 'catch ups' for nurses to manage the inherent challenges of good home care for patients and to develop a shared ethic of care and professional identity. Our findings also indicate the decline of 'catching up' between nurses along with diminishing time and opportunity for staff to care holistically for patients in present service climates.

The management of poor performance in nursing and midwifery: a case for concern.

AIM(S): To examine the evidence of how poorly performing nurses and midwives are managed in the UK National Health Service (NHS). BACKGROUND: Nurses and midwives form the largest clinical group in the NHS. There is little evidence, however, about poor performance and its management in nursing and midwifery literature. METHOD(S): The present study comprised a literature search, analysis of recent Nursing and Midwifery Council (NMC) data and observation at NMC fitness to practice hearings. RESULT: Nurses and midwives are the clinical groups most likely to be suspended in the NHS; Trusts do not report data on suspensions therefore no data exist on numbers, reasons for suspensions, managerial processes, gender, area of work, or ethnicity of those suspended; the few major research projects identify variable management practices, the significant financial cost to the NHS and the personal cost to those suspended; there is evidence that inexperienced, poorly trained, or poorly supported managers use suspension inappropriately. Our observation supported this. CONCLUSION(S): There is a need for robust data gathering and research in the field of NHS managerial practice. IMPLICATIONS FOR NURSING MANAGEMENT: Managers should refrain from adopting punitive forms of performance management. Frontline staff and management need better training and support for dealing with poor performance.

The sustainability of ideals, values and the nursing mandate: evidence from a longitudinal qualitative study.

This article reports on research that examines newly qualified UK nurses' experiences of implementing their ideals and values in contemporary nursing practice. Findings are presented from questionnaire and interview data from a longitudinal interpretive study of nurses' trajectories over time. On qualification nurses emerged with a coherent and strong set of espoused ideals around delivering high quality, patient-centred, holistic and evidence-based care. These were consistent with the current UK nursing mandate and had been transmitted and reinforced throughout their 'prequalification' programmes. The existence of professional and organisational constraints influenced their ability to implement these ideals and values once in practice. Data analysis revealed that within 2 years in practice the newly qualified nurses could be categorised as sustained idealists, compromised idealists, or crushed idealists. The majority experienced frustration and some level of 'burnout' as a consequence of their ideals and values being thwarted. This led to disillusionment, 'job-hopping' and, in some cases, a decision to leave the profession. These data are explored and discussed to inform the question of whether the current nursing mandate is sustainable.