Title: Care Under Pressure 2: Caring for the Carers – a realist review of interventions to minimise the incidence of mental ill-health in nurses, midwives and paramedics
Funder: Department of Health and Social Care

Abstract: The NHS needs healthy motivated staff to provide high quality patient care. Mental ill-health (eg.depression/anxiety) in healthcare staff is more common than in the general working population and explains over a quarter of NHS staff absence. This research focuses on nurses, midwives and paramedics - the clinical workforce with the highest rates of illness and sickness absence. It builds on a review of doctors’ mental ill-health, and is needed because the causes (and potential solutions) of nurses, midwives and paramedics mental ill-health are different._x000D_ In 2017 anxiety, depression or stress caused 11% of nurses to take sick leave, with rates climbing as high as 24% in some NHS organisations. A recent Royal College of Midwives’ survey reports almost 70% of midwives felt unwell in the past 12 months as a result of work-related stress. Since 2014, paramedics have been off work with stress, anxiety or depression for a total of 183,962 days (in 7 of England’s 10 NHS regions). Mental ill-health can cause staff to be emotionally exhausted, which can prevent them from doing a good job and connecting well with patients. Such staff don’t want to let their colleagues or patients down so may continue to work despite not being well. Others might decide to leave the NHS, either temporarily or permanently, meaning further staff shortages._x000D_ The aim of our project is to improve the mental health of nurses, midwives and paramedics. Specifically to: 1) Understand when and why nurses, midwives, and paramedics develop mental ill-health at work, and provide examples of where and how it is most experienced, 2) Find which strategies to reduce mental ill-health work best for these groups, how these strategies work and in what circumstances they are most helpful, 3) Design and develop resources for NHS managers/leaders so that they can understand how work affects the mental health of nurses, midwives and paramedics; and what they can do to improve their mental health in the workplace._x000D_ Aims 1) and 2) (above) will be met using a literature review method called a ‘realist review’ which is different to other review methods. Other types of literature reviews exist, but they often look at how things work ‘on average’ and do not take enough notice of the complexity of the problem and the different staff situations, work practices and varying contexts. Realist reviews focus on understanding not only if interventions work (or not) but how they work, why, and for whom they work and are useful in exploring different contexts at the individual, team or organisational levels. We will analyse a wide range of relevant literature (not only academic journal articles) and will identify the factors that contribute to the development of mental ill-health in nurses, midwives and paramedics. We will also be able to understand the best strategies for reducing mental ill-health, and under what circumstances these work best._x000D_ We are a team with expertise in staff wellbeing and realist reviews. We will search and make sense of the literature and share the findings with a stakeholder group which includes patient and public representatives and nurses, midwives and paramedics with experience of mental ill-health. This group will work with the researchers to understand the findings, and to design and develop resources for NHS managers/leaders; and produce reports and academic publications, as well as films, animations and plain English summaries to share the findings with a wide audience.

Lay abstract: Introduction:The NHS needs healthy, motivated nurses, midwives and paramedics to provide high quality patient care but these jobs are known to be very challenging. Staff shortages, high demand and increasing external scrutiny, is associated with a high prevalence of mental ill-health amongst healthcare staff. In 2015, the King’s Fund declared stress levels among NHS staff as ‘astonishingly high’ suggesting this was a public health issue. Our work builds on a current realist review examining doctors mental ill-health (Care Under Pressure(1):HS&DR-16/53/12). Our focus on NHS nurses, midwives and paramedics reflects the pressing recruitment and retention issues in these professions and their different experiences compared to doctors (e.g. lack of power/autonomy [nurses]; high litigation [midwives] and physical isolation [paramedics]). Nurses, midwives and paramedics are over 40% of the clinical workforce; have high rates of sickness absence due to mental ill-health with significant attrition and substantial financial implications. Changing the work environment to prevent the development of mental ill-health is preferable to alleviating 'symptoms', such as absenteeism and workforce attrition. Thus, strategies are needed that span the spectrum from prevention to treatment, and that target both individual and organisational behaviours._x000D_ _x000D_ Aim:To improve understanding of how, why and in what contexts nurses, midwives and paramedics experience work-related mental ill-health and determine which high-quality interventions can be implemented to minimise mental ill-health in these staff groups._x000D_ _x000D_ Methods:An evidence synthesis (realist review) to 1) understand when and why nurses, midwives, and paramedics develop mental ill-health at work, and where and how it is most experienced, 2) identify which strategies and interventions to reduce mental ill-health work best for these staff groups, how these work, and in what circumstances they are most helpful. We will engage with diverse stakeholders throughout (e.g. nurses, midwives and paramedics who have experienced mental illhealth, service managers, policy makers) to 3) design and develop resources for NHS managers/leaders to improve the mental health of nurses, midwives and paramedics in the workplace._x000D_ _x000D_ Results:The project will summarise how, why and in what circumstances mental ill-health is more likely to develop in nurses, midwives and paramedics; and what can remediate the situation for these different staff groups. Such knowledge will produce actionable theory to inform recommendations to support policy makers, health services decision makers, and local team leaders to select, tailor, implement and evaluate contextually-sensitive strategies to tackle mental ill-health and its impacts. This will inform the design of appropriate future support for nurses, midwives and paramedics experiencing mental ill-health._x000D_ _x000D_ Outputs:Using evidence from our review and informed by evidence-based implementation theory and stakeholder involvement we will identify and develop a range of resources for NHS managers/leaders. These outputs will support NHS managers/leaders to better understand how work affects the mental health of nurses, midwives and paramedics and identify what can be done to improve their mental health in the workplace. We will use innovative methods to develop these resources such as film, animation and info-graphics; plain English summaries and opinion pieces to facilitate wider dissemination.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH