Care Under Pressure 2: a realist review examining causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics

Taylor, Cath, Maben, Jill, Jagosh, Justin, Carrieri, Daniele, Briscoe, Simon, Klepacz, Naomi and Mattick, Karen (2023) Care Under Pressure 2: a realist review examining causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics. In HSR UK Conference 2023.

Abstract

Background: health service delivery requires healthy, motivated staff but there is a high and increasing incidence of psychological ill-health, exacerbated further by the COVID-19 pandemic. Nurses, midwives and paramedics are the largest collective group of clinical staff in the UK’s National Health Service and have some of the highest prevalence of psychological ill-health. Existing professional development and support is often profession-specific, and empirical evidence tends to focus on individual discrete interventions, which risk simplifying the causes and solutions to psychological ill-health.

Therefore, building on our previous work with doctors (Carrieri et al BMC Med 2020), this study asked:

1. Why is psychological ill-health in healthcare professionals still a huge and growing problem?
2. Why despite having interventions (some of which have an ‘evidence-base’) does the problem persist?
3. How we can optimise existing interventions, as well as innovating new ones?

Method: realist synthesis methodology was employed, following RAMESES reporting guidelines. First round database searching in MEDLINE ALL (via Ovid), CINAHL (via EBSCO) and HMIC (via Ovid), was undertaken February-March 2021, followed by more specific supplementary searching strategies (e.g., hand searching, expert solicitation of key papers). Subsequent database searches (December 2021) targeted COVID-19- specific literature and literature reviews. We developed novel approaches to characterise the state of education and practice for the three professions, manage the different-sized literatures, and co-produce the analysis.

Throughout the project, we worked closely with a stakeholder group comprising nurses, midwives, paramedics, representatives of patients and the public, educators, managers and policy makers. Via narrative and interactive activities, they provided insights into the nature, structure and stressors of their daily work, and we shared developing literature-based insights which they refined and shaped.

Results: we 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 (aspects of work that are incompatible and affect psychological ill-health) and identified five key findings, supported by 26 Context Mechanism and Outcome configurations (CMOcs). We learned that: interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; it is difficult to promote staff psychological wellness where there is a blame culture; the needs of the system often override staff wellbeing at work (‘serve & sacrifice’); there are unintended personal costs of upholding and implementing values at work; and it is challenging to design, identify and implement interventions to work optimally for diverse staff groups with diverse and interacting stressors.

Overall, we found more similarities than differences between professions in causes of psychological ill-health, and very few profession-specific interventions. In most cases it was the service architecture (organisational features, context and working practices) that increased risk rather than the profession itself. Staff appear particularly at risk when newly qualified, exposed to trauma, or under investigation. Individual characteristics including ethnicity, sexual orientation and/or gender identify, and disability require greater attention.

Implications: through identifying tensions in the literature, we have learned that healthcare as a provider and employer is a balancing act, with different considerations needing to be held in productive tension, such as the needs of staff and the needs of patients. Healthcare organisations need to urgently rebalance the working environment to enable healthcare professionals to recover and thrive. This will involve a focus on staff essential needs in order of priority and a commitment to reduce stigma and counter blame cultures, through long-term plans and investment. For the future, we need to identify and nurture future compassionate leaders and invest in multi-level systems approaches to promoting staff psychological wellbeing.

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Contributors

Author: Naomi Klepacz

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