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Maben J, Taylor C, Jagosh J, et al. Causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics: the Care Under Pressure 2 realist review. Southampton (UK): National Institute for Health and Care Research; 2024 Apr. (Health and Social Care Delivery Research, No. 12.09.)

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

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Chapter 5Strategies and interventions proposed for mitigating psychological ill-health in nurses, midwives and paramedics: a descriptive analysis

Introduction

This chapter reports on a descriptive analysis of the interventions that have been evaluated and/or are recommended to mitigate psychological ill-health in nurses, midwives and paramedics in our sample of included literature. Our aim is to provide an overview of the interventions in the included literature, and to provide a contemporary update on the focus of intervention research in nurses, midwives and/or paramedics in recent years. There have been many systematic and comprehensive reviews of workforce well-being interventions,25,150 so the aim of this realist review was to build on that work and take a wider lens by including grey and non-empirical literature, which may identify different types of interventions and/or help explain why the existing evidence-based interventions are not yet making sufficient difference to the psychological ill-health of the workforce. Akin to Chapter 4, this chapter provides an overview and context for the realist synthesis of the included literature (see Chapter 6) and starts to answer a key aim stated in our protocol: to identify which strategies/interventions to reduce psychological ill-health work best for these staff groups, find out how they work and in what circumstances these are most helpful.

See Chapter 3 for the methods.

In this chapter we aim to

  1. describe the interventions that are evaluated and/or recommended in the literature, according to
    1. their intended level of action: primary, secondary or tertiary (or multifocal);
    2. whether they are formal or informal interventions.
  2. compare the types of interventions evaluated and/or recommended in the literature according to ‘type’ of paper, and professional group (nurse, midwife, paramedic);
  3. assess the ‘fit’ of available interventions to the key causes identified in Chapter 3.

Results

The interventions were categorised according to their intended level of action (primary, secondary or tertiary) and whether they were formal or informal, though it was sometimes hard to attribute to these categories with confidence (see Tables 7–10).

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TABLE 7

Primary interventions evaluated and/or recommended according to whether formal or informal

Table Icon

TABLE 10

Multifocal interventions evaluated and/or recommended

In addition to the data presented in Tables 7–10, some of the papers described ‘negative’ or dysfunctional solutions to workplace stress, including leaving the profession105,148 or even suicide.95,101,105,109 Many also included mention of the need for interventions for students/pre-qualification,9,34,114,151 including the need for universities and NHS to work collaboratively to reduce the theory-practice gap90 (see Chapters 4 and 6). Student well-being is outside the remit for this study, so these interventions are not included here, though are acknowledged as being an important focus for any strategy to mitigate mental ill-health in the healthcare workforce.

Very few papers described interventions that did not work or should not be used. This is not surprising given the likelihood of publication bias (negative findings being much harder to publish), but such studies would be extremely helpful. Commentaries and editorials were mostly focused on what needed to be actioned and happen. Ineffective interventions included critical incident stress debriefing (CISD), reported as ‘neutral at best and harmful at worst with respect to preventing PTSD’18 (p. 2) due to interfering with natural recovery; and psychological first aid, which has been shown to have an impact on raising awareness of psychological well-being, but is not effective at changing behaviour,25 and argued to be simply ‘not enough’ due to the multifocal approach required to tackle the systemic issues87 (p. 1). There was also debate regarding the utility of OH in being part of the solution, being described as ‘rarely utilised and is seen by most members of staff as being for extreme cases’91 (p. 21), and the SOM report acknowledged the low uptake (and need for more clarity about their role and processes) and called for OH staff to have ‘training, resources and tools to meet the needs of staff’25 (p. 8).

Aim 1: describe the interventions that are evaluated and/or recommended in the literature

A total of 115 different types of interventions were either evaluated and/or recommended in the included literature. These spanned primary (n = 52), secondary (n = 46), tertiary (n = 6) ‘levels’, and multifocal (n = 11) interventions. A total of 71 of these were classified as being ‘formal’ interventions (including all tertiary and multifocal interventions) and 44 ‘informal’ interventions (see Tables 7–10).

Note: virtually all empirical reviews of interventions (and key reports) concluded with strong caution about the limitations of the evidence-base, being based upon studies that had weak designs and/or measures (e.g. lack of control groups, measures that had low reliability and/or validity) and inability to synthesise due to heterogeneity between studies.

The interventions are presented in Tables 7–10 and discussed according to their intended level of action below.

Primary interventions

Formal

Formal primary interventions (see Table 7) included several interventions with a pre-existing evidence-base that were whole systems/healthcare models, including the Buurtzorg model30,87 (originating in the Netherlands, aimed at providing a devolved holistic care system where nurses have a flat hierarchy and autonomy to provide person-centred care across health and social care boundaries), and US Magnet Recognition Scheme, currently being evaluated in the UK.30 Several papers also included reference to service/pathway models that enabled continuity of care and were associated with better staff well-being, such as the ‘caseload’ model in maternity;30,77,152 and three ‘good practice’ organisational interventions aimed at addressing inequality.30 Several sources across the nursing, midwifery and paramedic literature referenced frameworks, toolkits or standards to be used/followed/implemented in order to mitigate psychological ill-health. Some were profession-specific, such as a work-life balanced code of practice proposed by the now defunct Larrey Society (Ambulance Service Think Tank, est-2017),153 and others were NHS-wide, including the NHS Health and Wellbeing Framework.9,25,154

Primary interventions also included those focused on improving or changing working conditions, including tackling retirement barriers (e.g. reducing retirement age, allowing phased/partial retirement,77,95 and financial barriers to recruiting/retaining the workforce;155 and interventions that supported flexible working and/or gave workers more control over their work schedule.77,94 Several sources also referenced the benefit of or need for policy-level intervention, including the Assault on Emergency Workers Bill105 and ‘zero tolerance’123 (to support safety of staff at work). In relation to support and/or career progression, several sources across all three professions described the provision of formal mentorship/community practice schemes;110,119 only one training course was categorised at ‘organisational’ level and that was ‘implicit bias training’ recommended in an editorial focused on tackling racism in healthcare provision and wider society.79 At a societal level, two paramedic-focused editorials mentioned World Mental Health Day/World Suicide Prevention Day campaigns as ways of raising awareness of psychological ill-health in staff and/or encouraging action.105,121

Informal

There were many different ‘informal’ primary interventions recommended in the included literature (see Table 7). By their informal nature, these usually lacked clarity regarding definition or content. These included recommendations for culture change: for the NHS to take responsibility as an employer for staff well-being; to create a supportive and/or positive workplace culture; for systemic change (including calls for changes in attitudes towards mental health, meaningful recognition of the importance of staff well-being, and systemic approaches to development and provision of initiatives that support better staff well-being and welfare) and role modelling, for example, about the importance of self-care.81 ‘Good’ leadership was a key recommendation or intervention in many included sources, with ‘good’ being described variously as collective, shared, compassionate, person-centred, authentic, relational or sympathetic. While leadership training could be a formal intervention, and formal leadership courses exist for NHS staff, for example, HEE NHS Leadership Academy,159 and King’s Fund compassionate leadership training,160 no such ‘formal’ interventions were specially recommended or described in the included literature. In relation to frameworks, one high-profile report25 described the need for organisations to have a policy for managing stress/staff mental health with an action plan and strategy for implementation, highlighting the numerous previous ‘recommendations’ that have not been implemented as intended (or at all).

In the nursing and midwifery literature, there were various recommendations for changes to working conditions, including the introduction of minimum standards for facilities and working conditions;83 rotas based on realistic forecasting;30 and the development of alternative roles to support nurses and midwives (e.g. admin support staff, maternity support workers).30 One paper (examining nursing staff experiences in high secure forensic mental health settings111 argued a need for planned ‘time-out of the setting’ (p. 2904) with high-frequency of violence/aggression, a suggestion that would be likely equally applicable to other professions, such as paramedics and adult dementia care. Having planned ‘time out’ as an intervention is not new, being common to medical training.161 In relation to support/career progression, several sources described the often-overlooked role of the chaplaincy service in supporting staff well-being,35,96 and the importance of supporting the development of social and professional networks at work.158 One paper specifically mentioned the need to ensure that additional support and/or mentorship was put in place for what they described as ‘critical moments’, for example, when newly qualified, exposed to trauma, or subject to investigation/complaint.34 The importance that managers were provided with emotional support was highlighted in a further report.74

A key report30 recommended that learning and education in relation to mental health and well-being should be a feature throughout careers, and several sources recommended that training staff to recognise and act upon early signs of psychological distress was important.35,98,114,120,153 Two sources, both paramedic-focused, explicitly acknowledged the role of family, friends and loved ones in identifying, signposting and supporting staff impacted by experiences at work, and that they too should be offered such training.94,114 There were also several interventions aimed at wider well-being: diet and exercise focused.31 Finally, at the societal level, one paramedic-focused editorial131 acknowledged the positive impact of the general public showing kindness and compassion on emergency healthcare workers’ well-being (in relation to the Grenfell Fire major incident).

Secondary interventions

Formal

Formal interventions aimed at addressing essential needs at work were rare, but included one aimed at improving conditions and needs at work generally31 and specific initiatives regarding hydration and out of hours food for staff.30

A range of formal psychosocial interventions, based on mindfulness, were evaluated and/or recommended within many of the included sources (see Table 8). This included specific applications or platforms aimed at supporting practice of reflection/mindful activity. In addition, several nursing-focused papers recommended various psychosocial education programmes, including stress-management91 and resilience training,32 and positive psychology training programmes.106 These programmes included interventions such as ‘Three Good Things’106 and ‘Thankful Events’162 – both of which are underpinned by ‘positive psychology’ (Seligman163).

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TABLE 8

Secondary interventions evaluated and/or recommended according to whether formal or informal

There were several interventions that were specifically focused on reducing the risk of PTSD after exposure to traumatic events. The most reported intervention, used as a standard intervention in many UK Ambulance Trusts, is trauma risk management training (TRiM).9,18,33,35 Originating in the military, it is a trauma-focused peer support system based on ‘watchful waiting’ whereby trained ‘peers’ offer a first point of contact to share and discuss the traumatic event and signpost to professional help if needed.

It has been increasingly introduced to health care as an alternative to CISD, which has been shown to potentially cause harm (as mentioned earlier in this chapter). An alternative to TRiM mentioned in one paper is the Road to Mental Readiness Programme (originating in the Canadian military), consisting of mental health resilience education and training.114

Formal group reflection and/or debriefs were also cited in a range of sources across the three professions (see Table 8). Debriefing mostly focused on ‘hot’ debriefs: short structured debrief immediately after events, intended to defuse and allow processing and learning from what had been experienced.80,82,105 Reflective Practice Groups were also reported to support mental health and well-being: formal groups that facilitate reflection and critical thinking in a safe supportive environment.25,78

In relation to training in healthcare job-specific skills, communication skills’ programmes were reported to be associated with well-being benefit in two reviews,112,162 with one also reporting positive benefit from a Professional Identity Development Programme.162 Job-specific education/skills-training enhanced confidence and competence in the role according to two literature reviews (working with paediatric chronic pain for paediatric nurses,93 and assessment and treatment of schizophrenia for forensic nurses).162

Several organisation-specific initiatives were identified in included reports, including a Tea and Empathy group (national peer-to-peer support on Facebook)9 and #weCARE café, providing a café and garden space for staff to decompress, socialise and have access to listeners who can refer for further support if needed.30

Informal

Many of the sources referred to self-care in relation to the ‘essential’ elements of Maslow’s Hierarchy of Needs:170 the physiological needs (shelter, water, food, warmth, rest and health) at the bottom of the pyramid that need to be satisfied before individuals can attend to needs higher up the pyramid (including psychological). The importance of these needs being met was reinforced by many sources, with one report stating that a culture in which self-care is normalised is needed.9 Essential self-care informal interventions included having space and time for food, hydration, exercise, sleep, and having breaks/holidays from work (see references in Table 8). One report highlighted that work-specific needs are often lacking in the workplace: having lockers to keep belongings safe; access to showers; access to food (ideally healthy, hot) 24/7 etc.;9 and personal safety referred to in another.23

In relation to stress-management, many sources referred to the importance of using individual-focused relaxation, reflective and/or mindful practices, or using stress-management techniques and positive coping skills – and the benefit of such activities (without referencing specific formal interventions) (see references in Table 8). An informal intervention prevalent particularly in the paramedic literature (though also seen in nursing literature) was the use of humour – and dark humour – as a way of mitigating psychological ill-health.18,22,33,107,169 Understood as an informal aspect of service architecture for staff mental well-being, dark humour is noted in the literature as requiring a sensitive adoption so as not to upset or offend patients, members of the public, or other colleagues, and may take some adaptation for newly qualified staff.

Across all three professions, many sources referenced the importance of social support in relation to informal conversations with family, friends and colleagues (peer-support); and the importance of a positive team culture and having good relationships with colleagues18,111,116 (akin to findings from CUP-1,17 and other previous research highlighting the importance of the ‘family at work’140). This included the importance of team stability to well-being,30 for example, paramedics having a regular ‘work partner’ (crew member in the ambulance).18 Messaging such as ‘It’s OK to not be OK’ and ‘Be Kind’ were felt to be important messages to encourage a more open person-centred team culture. A ‘Going Home Checklist’ developed by Doncaster and Bassetlaw NHS Foundation Trust (https://www.dbth.nhs.uk/news/the-going-home-checklist/) suggests checking in with colleagues and texting a buddy as a way of perhaps attempting to formalise these important informal contacts.156 Having access to spaces where staff can socialise, share, discuss experiences and rest (with reference to the essential self-care above) was a key recommendation in several sources, and discussed further in Chapter 6. In a qualitative synthesis of psychological ill-health and help seeking in trauma-exposed emergency service staff,18 the importance of managers simply ‘checking in’ with staff was reported, provided it was perceived as being genuine and authentic (and not ‘tick-box’, something that may be altered if such an intervention became formalised, see Chapter 6).

Tertiary interventions

No ‘informal’ tertiary interventions were found in the included literature (see Table 9). This is perhaps not surprising given that these interventions are targeting those in whom psychological ill-health has been identified, and there are robust evidence-based guidelines for treatments.146,171 Interventions found in the NICE guidance were referenced as being helpful, such as cognitive–behavioural therapy (CBT), acceptance and commitment therapy (ACT), counselling and eye movement desensitisation and reprocessing (EMDR) (see references, Table 9). While several recommended counselling, one report stated the importance of this being independent from the employer,153 and an independent counselling service172 recommended in a commentary by a paramedic who had experienced psychological ill-health.109

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TABLE 9

Tertiary interventions evaluated and/or recommended (no informal interventions found)

Several sources recommended the provision of 24/7 telephone support, with one report recommending the development of a national NHS ‘Samaritans’ emotional support service,9 which since COVID-19 has been introduced.173 One paramedic-focused commentary recommended their Trust-specific ‘Staying Well Service’,174 which offers support and referral.109 A few papers also recommended complementary/alternative therapies.22,74,91

Multifocal interventions

Despite numerous reports over the past decade calling for systems approaches to well-being that target primary, secondary and tertiary levels25,150 we found relatively few interventions in the literature that had this aim, and no ‘informal’ interventions (see Table 10). Arguably the ‘intervention’ central to the NHS that should be primary, secondary and tertiary focused is OH, however as reported earlier in this chapter, OH is typically seen as being for extreme cases only and currently underutilised.

In relation to support for staff that straddled both primary (prevention) and secondary (mitigate impact of exposure) targets, several sources recommended and/or evaluated preceptorship programmes for newly qualified staff and clinical supervision models for all staff, particularly in nursing and midwifery. Preceptorship programmes have been found to vary widely,73 and a range of different supervision models were cited, including the following: resilience-based; CBT-based; restorative supervision; and person-centred resilience-based supervision models (see Table 10), as well as the professional midwife

advocate model (which has recently been adapted for nursing).176 In some professions/roles, clinical supervision is mandated, but in others remains a voluntary component of the job, and there are calls for changing this to ensure supportive networks are in place for staff, for example.156

Aside from these training and support interventions, there were some specific interventions and programmes recommended in the literature including Schwartz Rounds, a rare example of a whole organisation group reflection intervention that enables sharing and hearing of the emotional, ethical and social challenges of work in a safe, confidential, structured space. Schwartz Rounds have an evidence base demonstrating benefits at individual and organisational levels140,177 in relation to staff well-being and culture change (thereby straddling primary and secondary targets). In the paramedic-focussed literature, a key multifocal intervention cited by many sources is Mind’s Blue Light Programme178 providing information and advice as well as access to urgent help if needed (via a confidential helpline or text service to trained volunteers). Similar support is provided via The Ambulance Services Charity.179 Finally in the midwifery literature an intervention called POPPY (Programme for the Prevention of PTSD in midwifery) has been evaluated positively,103 consisting of a stepped care process combining education and supportive resources, including access to trauma-focussed clinical psychology if required.

Aim 2: compare the types of interventions evaluated and/or recommended in the literature according to ‘type’ of paper, and professional group (nurse, midwife, paramedic)

Types of interventions in empirical literature versus non-empirical literature

Examination of the literature from the initial search that focussed on interventions to prevent/mitigate staff psychological ill-health (n = 39/75 sources) showed that empirical papers that evaluated interventions (n = 10/39 nursing = 7, midwifery = 3, paramedic = 0) focused on one single intervention (6/10) or intervention programme (4/10), compared to editorials/commentaries (n = 29/39) in which most (16/29) had a multifocal focus, recommending multiple interventions (range 1–10, mean 3.3 interventions per paper).

In addition, empirical papers all focused on ‘formal’ interventions (10/10) mostly aimed at individuals (6/10) (i.e. mindfulness training or clinical supervision/preceptorship), whereas only seven editorials and commentaries focused solely on formal interventions, most describing/recommending a mixture of formal and informal interventions (n = 15/29) (see Appendix 8, Tables 26–28).

In terms of interventions: three evaluated mindfulness training,108,144,164 four focused on clinical supervision or preceptorship,73,118,127,175 two evaluated interventions aimed at lessening the effects of exposure to work related trauma,78,103 and one was a career progression programme110 (see Appendix 8, Table 27).

The 29 literature reviews included in our review (which comprised qualitative evidence syntheses and those focused on explaining causes and solutions, as well as systematic reviews of interventions) revealed a different picture (see Appendix 8, Table 29). Five did not include reference to any interventions. Seven aimed to evaluate interventions, and of these all except one were focussed on secondary level interventions. The exception was Brand et al.,31 which aimed to identify and evaluate whole-systems approaches to well-being and identified a range of different multifocal programmes.

Types of interventions by professional group

The focus of included evaluation studies (either primary or secondary evidence) was predominantly secondary level (e.g. mindfulness, stress-management programmes) across all three professions. Of the ten empirical papers, three focused on newly qualified nurses/midwives; two on midwives, and five on a range of different types of nurses (see Appendix 8, Table 27). When including the wider literature from commentaries and editorials, there were few differences by professional group: though paramedic-focussed papers tended to focus on secondary level intervention (for trauma) more than nursing and midwifery papers (see Appendix 8, Table 28).

Aim 3: assess the ‘fit’ of available interventions to the key causes identified in Chapter 3

The identified interventions were mapped to the causes identified in Chapter 3, based on the intended key aim of interventions. We then graded the causes: red, amber or green according to the extent to which interventions that tackled these causes existed in the literature (see Appendix 9, Table 29).

Note: important caveats are that (1) the literature we included may not reflect what is actually happening on the ground; (2) we did not run searches specifically for interventions aimed at these causes; (3) the mapping and categorisation process require an element of judgement and may not be comprehensive but is intended as a starting point for identifying major gaps between causes and interventions.

The results of this process indicated that for the majority of the causes, there exist some formal and/or informal interventions but more evidence and work is needed; areas where intervention knowledge appears strongest are for exposure to trauma (including experiencing death); there are several identified causes of psychological ill-health where there may be no interventions currently, this includes many of the identified profession-specific causes (and thereby the ‘who’ and ‘when’ factors), including service architecture features such as working on call; lacking continuity of care; unnecessary call-outs; high risk of sustaining injury; being a profession under scrutiny; lone working; fear of assault/abuse from the public/patients. We also found no interventions aimed specifically at supporting staff through investigations or complaints despite this being a known key cause of psychological ill-health.

Key findings

The overarching findings from this descriptive analysis are as follows:

  • there are many ‘informal’ interventions that are cited to be beneficial or recommended, some of which have been formalised or could be formalised. These are perhaps informally developed to plug gaps in current provision and may help explain why current provision is not working to mitigate psychological ill-health;
  • interventions (both formal and informal) exist at primary, secondary and tertiary levels, most focus on individuals; very few interventions were profession specific;
  • few of the interventions that we found in this review were tertiary or multifocal ‘systems’ approaches, and we found no informal examples of these. Tertiary interventions are generally well evidenced (e.g. evidenced in NICE guidance), but our review suggests multifocal interventions are under-researched;
  • more attention needs to be paid to how the primary, secondary and tertiary levels can and should work together to provide a systems approach to prevent, mitigate, and treat psychological ill-health in staff;
  • most empirical papers evaluating interventions focussed on one single intervention, whereas most editorials and commentaries recognised the need for multi-level systems approaches;
  • interventions and strategies in the literature tended to focus on short-term goals, simplify and reduce issues and not take into account complexity, probably because this is practically and methodologically easier.
Copyright © 2024 Maben et al.

This work was produced by Maben et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaptation in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/. For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited.

Bookshelf ID: NBK603151
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