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NHS Workforce mental health: Better support through multi-level approaches

By 05/11/2024November 19th, 2024No Comments

In the wake of world mental health day, we discuss the importance of supporting NHS staff mental health through multi-level, comprehensive approaches – addressing culture, processes, workplace environment and individual support. We also share some examples of work we’re doing to develop and evaluate strategies and interventions to do just this.

photo of nurses waking in a hospital

Healthcare professionals’ work is intrinsically emotionally complex and demanding, with routine exposure to multiple psychosocial occupational health risks, including:

  • Breaking difficult, life-changing news.
  • Involvement in adverse events/patient safety incidents.
  • Cumulative stress and vicarious trauma from repeated exposure to pain, suffering and death.
  • Fatigue from long working hours and shift work.

Occupational health risks for healthcare professionals intensified unimaginably during the COVID-19 pandemic1,2,3. Now well documented, these included: trying to provide adequate care for unprecedented numbers of sick and dying patients, inadequate/no training or Personal Protective Equipment, working long shifts in uncomfortable, restrictive PPE in often unthinkable conditions (e.g., on pop up wards with no access to running water) and redeployment to unfamiliar teams and specialities. The way in which mass redeployment and other aspects of work were managed during the pandemic triggered, for some, feelings of injustice, broken psychological contracts and resentment2,3.

For healthcare professionals employed by the UK National Health Service – the largest employer in Europe4 and fifth largest in the world5 – working through the pandemic exacerbated already unprecedented levels of stress, burnout and sickness after a decade of austerity6, with health worker cuts, pay freezes and staff shortages7. During austerity, reports of work-related stress shot up from 28% in 2009 to 40% in 2018, and burnout affected around 33% of doctors and nurses in 20168. Fast forward to post-pandemic and the latest NHS staff survey9 shows that:

  • 42% of staff have felt unwell due to work-related stress in the last year.
  • 55% have gone into work in the last 3 months despite not feeling well enough.
  • More than a third (34%) find their work emotionally exhausting.
  • 43% feel worn out at the end of the day.
  • Just over 30% feel burnout because of their work (42% of ambulance staff).

The NHS recognises that its workforce is under extreme strain. Lord Darzi’s10 recent independent investigation into the NHS in England highlights grave concerns over staff wellbeing and notes a sharp decline in the trust, goodwill and discretionary effort of staff. There’s a growing sense that, post-COVID, healthcare staff are less willing to tolerate poor care and treatment from their employers11. Just under 30% of NHS staff often think about leaving their profession altogether9; in the year to June 2024, 10% (151,000) actually left their role12. NHS job vacancies currently run higher than the overall UK’s (7.7% vs. 2.7%)13. An over-arching, recurrent theme from a recent analysis of ‘reasons for resignation’ given by outgoing NHS staff14 (see Figure 1) was that trying to do their job in sub-optimal conditions prevents staff from fulfilling their intrinsic need to honour their professional standards. Similarly, Lord Darzi’s10 report acknowledged that staff have to routinely divert their attention from caring for patients to deal with process problems and inefficient systems they “lack the power to fix” (p. 113). These sub-optimal conditions cause frustration and anxiety about patient safety.

Reasons for leaving bar chart

The latest NHS staff survey results support these findings:

  • 33% of staff said they’d seen errors, near misses or incidents that could have hurt patients/service users/staff in the past month.
  • Less than two-thirds (59%) felt their organisation treated staff involved in an error, near miss or incident fairly.
  • Less than a third (32%) said there are enough staff for them to do their job properly.
  • Less than half (47%) felt able to meet all the conflicting demands on their time.
  • Only around half (51%) are involved in deciding on changes introduced that affect work.
  • Just over half (56%) feel able to make improvements happen in their area of work.

Clearly, change is urgently needed, but no one is naïve enough to think there’s a quick fix10,15. There is growing pressure for healthcare organisations to strike a better balance between the high quality of care they expect to provide to patients as a service and the care they currently provide to staff as an employer6, 16:

“Healthcare organisations have a duty to protect employees and provide an environment where staff can thrive” (Taylor et al., 2024, p. 533).

So how do we best support NHS staff wellbeing?

Our own research revealed a cynicism towards some of the well-intentioned wellbeing support offered during COVID, such as counselling, yoga, mindfulness. These were sometimes referred to as ‘tokenistic’, when even the most basic conditions like breaks, sufficient water and somewhere to rest, were not provided2,3. Similarly, staff have referred to wellbeing checks as a ‘tick box’ exercise16. The reality is, when staff are asked about what factors would have the greatest impact on their wellbeing at work, they overwhelmingly say better communication, staffing and interpersonal connectivity, rather than issues targeted by wellbeing programmes17. We need to address workforce wellbeing in a more systemic, sustained and multi-layered way – focusing on proactive stress prevention as well as remedial support when stress is experienced15, 16, 18.  A recent review16 made four clear recommendations “to enable healthcare professionals to recover and thrive” (p.523; See Figure 2):

recommendations to promote recovery table

A multi-level Organisational Staff Support Model

These recommendations reflect longstanding, good practice for stress management19-21  which advocates building a comprehensive, ‘3-pronged’ organisational wellbeing strategy (see Figure 3, our ‘Multilevel Organisational Staff Support Model’, which describes this). We’ve adapted this well-respected stress management model for healthcare professionals and conceptualised as a pyramid, with primary prevention as the foundational aim (see our staff support website).

Multi level organisational staff support model

 

Interventions within such a multi-level strategy may target changes in workplaceconditions or inthe worker, and sometimes both22 more specifically, at the level of organisation, leader, group or individual23 (see Table 1). Organisational interventions that target work conditions and function as a preventative/primary approach to reducing occupational stress may be more effective than individual interventions, according to growing evidence22, 24, 25. However, they are far more difficult to deliver and are the least studied to date. Changing work conditions is linked to positive effects in work-wellbeing, which spill over into general wellbeing, home and family life22. Organisations can boost interventions by targeting different levels together (e.g. organisation- and group-level changes). It is more effective to mix organisation- and individual-level aspects in an intervention than focusing on either in isolation22, 24. This is particularly the case for the successful treatment of physician burnout, according to a large systematic review and meta-analysis26.

 

Table - difference levels of change
What work are we doing at the NIHR Yorkshire and Humber Patient Safety Research Collaboration to address workforce wellbeing? Here are some examples

At the Patient Safety Research Centre we’ve been focusing heavily on the Primary prevention space, researching organisational-level approaches to promote wellbeing, prevent harm. We share some examples here, including:

  • An intervention to prepare healthcare professionals for involvement in adverse and other stressful clinical events.
  • Recommendations for the redeployment of staff, following learning from the COVID-19 pandemic.
  • Investigating reducing job demands by ‘decluttering’ work processes.
  • The development of processes and tools to support a Just Culture within the NHS.

These all speak  directly to the recommendations14 in Table 1 to enable healthcare professionals’ recovery and flourishing.

1)An intervention to prepare healthcare professionals for involvement in adverse and other stressful clinical events

The Reboot (Recovery Boosting Training) intervention is a training programme based on Cognitive Behaviour Therapy principles which helps prepare health professionals for involvement in stressful clinical situations during the course of their work. Delivered by a trained CBT therapist or clinical psychologist, it primarily targets mental flexibility and building a personal toolkit for managing stressful events. Originally piloted as a half day face-to-face workshop with a follow-up one-to-one coaching call8,27, this evolved during the pandemic into two shorter online sessions with a follow-up call28,29. Reboot has been repeatedly found to be associated with reductions in burnout and depression and increases in confidence and resilience, when delivered to multiple healthcare professional groups, including: critical care nurses30, medical students28, midwives, paramedics, doctors, trainees, including sonographers, mammographers and physician associates8, 27 and urologists29. Recent funding from the Medical Protection Society will support more robust evaluation of the intervention.

 

2) Good practice in redeployment: The Redeploy Study

Nurses, the biggest occupational group in the NHS, were widely impacted by redeployment during the pandemic. We sought to understand their redeployment experiences and how this affected their well-being, job performance and intentions to leave2,3. We spoke to 100 nurses working at three different acute NHS Trusts in England during the COVID-19 pandemic. We then carried out workshops with national senior stakeholders from: Health Education England; Nursing and Midwifery Council; Royal College of Nursing; Unison; NHS Employers; NHS England and Improvement; NHS Providers; Improvement Academy; Care Opinion (patient perspective); and nursing academics.

We found that redeployment had a huge impact on nurses, including those redeployed, in teams who received redeployed nurses and managers who implemented redeployment. There was a lack of guidance and support for nurse managers, leading to inconsistent redeployment approaches both within and across Trusts. Whilst redeployment had a positive, flourishing impact on some, overall, redeployment was perceived as a contentious, unpleasant task for all involved in the process, and often led to incivility between staff. This negatively impacted those who were asked to be redeployed.

From this research2,3, we developed two reports to improve redeployment processes and experiences going forward: (1) The Recommendations for the management of NHS nurse redeployment and crisis workforce recovery: A guide for acute NHS Trusts and (2) Nurse redeployment: A good practice guide. These are available here: https://yqsr.org/redeployment-of-nurses-in-hospitals-redeploy/

 

3) Decluttering (safely) for patient safety

There is a growing literature focusing on clinical practices that are of low-value, at least for some patients, in some circumstances (for example, unnecessary scans, medicines or procedures). The Choose Wisely campaign identifies and recommends the de-implementation of these practices across different clinical specialities. As a group interested in patient safety, we set out to identify practices and tasks that are encouraged ‘in the name of safety’ but for which there is limited or no evidence of their benefit for safety. These are called ‘low-value’ safety practices.  Some examples of low-value practices include duplicative risk assessments, and double-checking, that add to the workload of healthcare staff without improving patient safety. Many believe that healthcare systems have become overly burdened by these practices which may exist as much to manage the risk of complaints or claims as to manage the risk to patients. Currently, our understanding of which safety practices are of low value and how best to remove those that are is poor. Our de-cluttering (safely) for safety theme examines the process of reducing the burden of excessive procedures, medicines and alerts. Specifically, we are examining:

(1) Reducing ineffective safety practices.

(2) Reducing problematic polypharmacy.

(3) Rationalising clinical decision support systems.

For more information, click here:  https://psrc-yh.nihr.ac.uk/psrc_themes/de-cluttering-safely-for-safety/

 

4) Tools and processes to support a Just Culture

Evidence-based resources to aid healthcare staff coping after an adverse event: In collaboration with the Yorkshire and Humber Improvement Academy, we created a resource-filled website to support staff and leaders around adverse events. This involves videos of doctors and nurses who have shared with us their personal experiences of being involved in adverse events. The website brings together the research which highlights the issues staff face when they are involved in a patient safety incident or error. The resources and best practice examples can be used to help alleviate the impact of being involved in a patient safety incident on healthcare staff.

A tool to support NHS organisations implement a just culture framework: In collaboration with our partners the Yorkshire and Humber Improvement Academy, we created a Just Culture Assessment Framework tool, which organisations can use to start changing and monitoring their psychological safety and just culture. Support is available from the Academy for organisations to implement this.

Understanding what support staff want after adverse events: We undertook an extensive systematic review to understand what healthcare staff really want to help them cope with adverse events, what they tend to receive and how effective it is.  Currently under review, this research demonstrated that healthcare staff are not routinely getting the help they want: secondary approaches (particular peer support programmes) dominate, and primary, preparatory approaches are uncommon.

 

What next?

Historically the NHS has been a great source of pride, but, working in a broken system, its workforce has simply been ‘unable to defy the odds and deliver great performance’10 p.11.

In this blog, we’ve argued for the need to support NHS workforce wellbeing through multi-level, comprehensive approaches – addressing culture, processes, workplace environment and individual support. We’ve also shared some examples of work we’re doing in this area. Lord Darzi’s report8 has identified as a top priority the need to re-engage NHS staff and harness their talents for positive change. In order to support and retain a committed, healthy and happy workforce across both health and social care sectors, we need to shape working environments where staff are able to exercise agency and fulfil their intrinsic need to honour their professional standards. A crucial area for future focus must now be how to establish effective processes for listening to staff and using this information to make collaborative changes to the design, social and physical environment and leadership of work.

 

Dr Ruth Simms-Ellis (PhD) is a chartered psychologist specialising in work psychology, based in the Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research.

 

References

  1. Dunn, M., Sheehan, M., Hordern, J., Turnham, H. L., & Wilkinson, D. (2020). ‘Your country needs you’: the ethics of allocating staff to high-risk clinical roles in the management of patients with COVID-19. Journal of Medical Ethics, 46(7), 436-440. https://doi.org/10.1136/medethics-2020-106284
  2. Hartley, H., Dunning, A., Dunn, M., Grange, A., Murray, J., Simms-Ellis, R., Unsworth, K., Marran, J. & Lawton, R., 2024. Managing nurse redeployment during the Covid-19 pandemic, lessons for future redeployment: A qualitative study. International Journal of Nursing Studies, p.104828.
  3. Dunning, A., Hartley, H., Unsworth, K., Simms-Ellis, R., Dunn, M., Grange, A., Murray, J., Marran, J. & Lawton, R., 2024. Nurses’ experiences and sense making of COVID-19 redeployment and the impact on well-being, performance, and turnover intentions: A longitudinal multimethod study. International Journal of Nursing Studies Advances, p.100244.
  4. NHS England (2023). NHS long term workforce plan, June 2023. Available at: https://www.england.nhs.uk/wp-content/uploads/2023/06/nhs-long-term-workforce-plan-v1.2.pdf [Accessed 10th Oct 2024].
  5. Nuffield Trust (2024) The NHS workforce in numbers: Facts on staffing and staff shortages in England, 07/02/2024.Available at: https://www.nuffieldtrust.org.uk/resource/the-nhs-workforce-in-numbers#:~:text=The%20number%20of%20hospital%20and,coming%20out%20ahead%20of%20pay. [Accessed 10th Oct 2024].
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  27. Janes, G., Harrison, R., Johnson, J., Simms‐Ellis, R., Mills, T., & Lawton, R. (2022). Multiple meanings of resilience: Health professionals’ experiences of a dual element training intervention designed to help them prepare for coping with error. Journal of Evaluation in Clinical Practice, 28(2), 315-323. https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/jep.13555
  28. Johnson, J., Pointon, L., Talbot, R., Coleman, R., Budworth, L., Simms-Ellis, R., Vogt, K., Tsimpida, D., Biyani, C.S., Harrison, R. and Cheung, G., 2024. Reboot coaching programme: a mixed-methods evaluation assessing resilience, confidence, burnout and depression in medical students. Scottish Medical Journal, 69(1), pp.10-17. https://journals.sagepub.com/doi/pdf/10.1177/00369330231213981
  29. Al‐Ghunaim, T., Johnson, J., Biyani, C.S., Coleman, R., Simms‐Ellis, R. and O’Connor, D.B., 2023. Evaluation of the reboot coaching workshops among urology trainees: A mixed method approach. BJUI compass, 4(5), pp.533-542 https://bjui-journals.onlinelibrary.wiley.com/doi/pdf/10.1002/bco2.249
  30. Vogt, K. S., Grange, A., Johnson, J., Marran, J., Budworth, L., Coleman, R., & Simms-Ellis, R. (2022). Study protocol for the online adaptation and evaluation of the ‘Reboot’(Recovery-boosting) coaching programme, to prepare critical care nurses for, and aid recovery after, stressful clinical events. Pilot and Feasibility Studies, 8(1),63 https://doi.org/10.1186/s40814-022-01014-2.

 

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