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.

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.

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.

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.

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.

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.

Clinician stakeholder experiences of a new youth mental health model in Australia: A qualitative study.

AIM: Late teens and early adulthood is the peak age of onset for mental disorders. Currently, there is a gap between primary mental health care and more intensive mental health services for young people in New South Wales (NSW), Australia. Two headspace Early Intervention Teams (hEITs) were developed to bridge this gap in Sydney Local Health District (SLHD), in Sydney, Australia. This study aims to explore clinician experiences of hEIT after the first 2 years of implementation. METHODS: Semistructured interviews were conducted with key clinicians working within hEIT or closely associated with hEIT. Nine interviews were conducted, transcribed and analysed using qualitative thematic analysis. RESULTS: Four themes were identified: (1) building a bridge between services, (2) filling a clinical gap, (3) service collaborations and their challenges and (4) difficulties of small team size. CONCLUSIONS: There is evidence that clinicians value the service provided by hEIT. There are difficulties such as referral confusion, staff turnover and suggestions to increase staffing to improve the stability, skill diversity and viability of the service. Findings have implications for other collaborative youth mental health models.

Evaluation of a workshop using verbatim theatre stimuli to address challenging workplace situations: a pilot study.

BACKGROUND: Challenging workplace situations such as bullying, harassment, depression, suicide and fatigue exist in health care. The performing arts can generate dialogue and engagement with these difficult issues. This study evaluates a workshop for health care students that used filmed vignettes from a verbatim theatre play that used real stories of such situations. The workshop aimed to improve health professional students' confidence in seeking help for depression, addressing mistreatment, understanding mandatory reporting laws and the impact of driver fatigue. METHODS: Two workshops were held: one with a mixture of professions, including nursing, medical and allied health students, and the other with medical students only. Participants completed questionnaires before and after each workshop, responding to four Likert questions on understanding and confidence about the issues discussed and free-text responses about the perceived value of the workshop. RESULTS: Sixty-five people took part in the workshops, with a 100% response rate to the pre-workshop survey and a 98% response rate (n = 64) to the post workshop survey. Students most frequently reported an improvement in understanding mandatory reporting laws (57%), followed by an increase in confidence in dealing with bullying and harassment (44%). Students in the workshop with a mix of professions noted the benefit of learning about these challenging issues alongside students from other health professions. DISCUSSION: Students valued the facilitated discussion of sensitive issues. Although many respondents increased their understanding or confidence in the four topics, a smaller proportion reported a reduction after the workshop. Perhaps this resulted from greater appreciation of the complexities of these issues. Health care students valued hearing from other professional groups in the mixed professions workshop.

Psychiatry peer review groups in Australia: a mixed-methods exploration of structure and function.

OBJECTIVES: The purpose of this study was to examine Australian psychiatrists' experience of participation in a small group learning format of continuing professional development, known as peer review groups (PRGs), with a particular emphasis on group structure and functions. METHOD: An exploratory mixed-methods study comprising a survey (n=77) and semistructured interviews (n=6) with Australian psychiatrists participating in a PRG in the previous 12 months. RESULTS: Qualitative findings indicate that PRGs address experiential learning through a focus on both breadth and specificity of work, as well as participants' experiences. Participants described using PRGs as a forum to manage difficult and complex work (through critiquing work, learning from one another, considering theory and guidelines, benchmarking, validating, reflecting and generalising learning) and to manage stress and well-being associated with crises, everyday stress and professional isolation. Particular structural aspects of PRGs considered essential to achieve these functions were self-selection of members, self-direction of meeting content and provision of a safe environment. These findings were convergent with the quantitative findings from scale survey data. Difficulties experienced during PRG participation are also described. CONCLUSION: Qualitative and quantitative findings from psychiatry PRGs demonstrate how practice-based professional experience functions as both a source of learning and of collegial connection that contributes to well-being and reduction in professional stress. Study limitations and future research directions are discussed.

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.

Psychiatric morbidity, burnout and distress in Australian physician trainees.

Objective The aim of this study was to evaluate the prevalence of psychiatric morbidity, alcohol use, burnout and compassion satisfaction among physician trainees in New South Wales, Australia, and examine links between personal, demographic and lifestyle factors. Methods A total of 67 physician trainees were recruited to the study. Fifty-nine completed the online survey (88% response rate). Outcome measures included the Depression Anxiety Stress Scale, Professional Quality of Life Scale and Alcohol Use Disorders Identification Test. Results Approximately half the respondents met screening criteria for depression (53%), stress (51%) and anxiety (46%). Secondary traumatic stress was exceptionally high across the cohort, with higher scores in females (P=0.001). The main reasons for not seeking help for depression or anxiety were lack of time (81%), fear of lack of confidentiality or privacy (41%), embarrassment (39%) and effect on registration (27%). Eighty-eight per cent of respondents agreed that doctors feel they need to portray a healthy image, but only 54% engaged in regular exercise and 24% slept ≤6h each day. Conclusion The results demonstrate high levels of non-psychotic psychiatric morbidity among physician trainees and a need to improve their well-being. Workplace systems need to promote healthy work environments and support physician trainees through good mentorship and supervision. What is known about the topic? Doctors' health and patient care can be affected when doctors experience burnout and psychiatric morbidity. What does this paper add? This paper adds to the evidence of psychiatric morbidity, burnout, secondary trauma and increased demographic data on a cohort of junior doctors undertaking speciality training. In addition, it provides reasons for not seeking help and positive and negative coping methods used by these junior doctors. What are the implications for practitioners? The level of distress is high and requires system changes to support both individual health measures and structural change to work and study programs.

Complaint risk among mental health practitioners compared with physical health practitioners: a retrospective cohort study of complaints to health regulators in Australia.

OBJECTIVES: To understand complaint risk among mental health practitioners compared with physical health practitioners. DESIGN: Retrospective cohort study, using incidence rate ratios (IRRs) to analyse complaint risk and a multivariate regression model to identify predictors of complaints. SETTING: National study using complaints data from health regulators in Australia. PARTICIPANTS: All psychiatrists and psychologists ('mental health practitioners') and all physicians, optometrists, physiotherapists, osteopaths and chiropractors ('physical health practitioners') registered to practice in Australia between 2011 and 2016. OUTCOME MEASURES: Incidence rates, source and nature of complaints to regulators. RESULTS: In total, 7903 complaints were lodged with regulators over the 6-year period. Most complaints were lodged by patients and their families. Mental health practitioners had a complaint rate that was more than twice that of physical health practitioners (complaints per 1000 practice years: psychiatrists 119.1 vs physicians 48.0, p<0.001; psychologists 21.9 vs other allied health 7.5, p<0.001). Their risk of complaints was especially high in relation to reports, records, confidentiality, interpersonal behaviour, sexual boundary breaches and the mental health of the practitioner. Among mental health practitioners, male practitioners (psychiatrists IRR: 1.61, 95% CI 1.39 to 1.85; psychologists IRR: 1.85, 95% CI 1.65 to 2.07) and older practitioners (≥65 years compared with 36-45 years: psychiatrists IRR 2.37, 95% CI 1.95 to 2.89; psychologists IRR 1.78, 95% CI 1.47 to 2.14) were at increased risk of complaints. CONCLUSIONS: Mental health practitioners were more likely to be the subject of complaints than physical health practitioners. Areas of increased risk are related to professional ethics, communication skills and the health of mental health practitioners themselves. Further research could usefully explore whether addressing these risk factors through training, professional development and practitioner health initiatives may reduce the risk of complaints about mental health practitioners.

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.

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.

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.

Bullying and sexual harassment of junior doctors in New South Wales, Australia: rate and reporting outcomes.

Objective The aim of this study was to describe rates of exposure to bullying and sexual harassment in junior doctors in first- or second-year prevocational medical training (PGY1 or PGY2 respectively) positions in New South Wales (NSW) and the Australian Capital Territory (ACT), and to explore the types of actions taken in response. Methods A cross-sectional survey of junior doctors in PGY1 or PGY2 positions was undertaken in 2015 and 2016 (n=374 and 440 respectively). Thematic analysis was undertaken on free-text responses to describe the reporting process and outcomes in more depth. Results The estimated response rate was 17-20%. Results from both surveys followed almost identical trends. Most respondents in 2015 and 2016 reported being bullied (n=203 (54.3%) and 253 (57.5%) respectively), 16-19% reported sexual harassment (n=58 and 82 respectively) and 29% of females reported sexual harassment. Qualitative analysis elucidated reasons for not taking action in response to bullying and harassment, including workplace normalisation of these behaviours, fear of reprisal and lack of knowledge or confidence in the reporting process. For respondents who did take action, most reported ineffective or personally harmful outcomes when reporting to senior colleagues, including being dismissed or blamed, and an intention not to trust the process in the future. Conclusions The findings suggest that interventions targeted at the level of junior doctors to improve the culture of bullying and harassment in medicine are unlikely to be helpful. Different approaches that address the problem in a more systemic way are needed, as is further research about the effectiveness of such interventions. What is known about the topic? Bullying and sexual harassment are common workplace experiences in the medical profession. What does this paper add? Over half the junior doctors in the present study experienced bullying and nearly one-fifth experienced sexual harassment. Junior doctors are reluctant to speak out, not only for fear of reprisal, but also because they do not believe it is worth doing so. What are the implications for practitioners? The data confirm a systemic problem of bullying in NSW. Primarily focusing on interventions with junior doctors (e.g. resilience training) is unlikely to solve the problem. Different and multipronged approaches (e.g. raising awareness in senior colleagues and training bystanders to intervene) should be tried and studied.

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.

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.

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.