Care Under Pressure 2: a realist synthesis of causes and interventions to mitigate psychological ill-health in nurses, midwives and paramedics

Abstract

Background: nurses, midwives and paramedics comprise over half the clinical workforce in the UK NHS and have some of the highest prevalence of psychological ill-health. This study explored why psychological ill-health is a growing problem and how we might change this.

Methods: a realist synthesis involved iterative searches of within MEDLINE, CINAHL and HMIC, supplementary handsearching and expert solicitation. We used reverse chronological quota screening and appraisal journaling to analyse each source and refine our initial programme theory. A stakeholder group comprising nurses, midwives, paramedics, patients and public representatives, educators, managers and policy makers contributed throughout.

Results: following initial theory development from 8 key reports, 159 sources were included. We identified 26 CMOcs, with 16 explaining causes of psychological ill-health, and 10 explaining why interventions have not worked to mitigate psychological ill-health. These synthesised to five key findings: (1) it is difficult to promote staff psychological wellness where there is a blame culture; (2) the needs of the system often override staff psychological wellbeing at work; (3) there are unintended personal costs of upholding and implementing values at work; (4) interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stressors; and (5) it is challenging to design, identify and implement interventions.

Conclusions: our final programme theory argues the need for healthcare organisations to rebalance the working environment to enable healthcare professionals to recover and thrive. This requires high standards for patient care to be balanced with high standards for staff psychological wellbeing; professional accountability to be balanced with having a listening, learning culture; reactive responsive interventions to be balanced by having proactive preventative interventions, and the individual focus balanced by an organisational focus.

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ORCID for Naomi Klepacz: orcid.org/0000-0001-7552-8000

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