Aim (a) to describe the differences in demographic, structural features of work (service architecture), and well-being indicators between nurses, midwives and paramedics, and also compare to doctors
We extracted and compared key demographic, service architecture (structural features of work) and well-being indicators for nurses, midwives and paramedics, as well as doctors. See Chapter 2, Step 1B for methods of the critical review we undertook, and Report Supplementary Material 1 for the full publication.4 The comparison with doctors was important since this review built on CUP-1,17 which focused on doctors. Key differences that we found between the professions, that may be important to fully understand causes and interventions to mitigate psychological ill-health include the following:
Demographic
Gender: nursing and midwifery are female-dominated, whereas doctors and paramedics are more balanced. Various social and economic factors (e.g. being more likely to take on caring roles, live in poverty and experience domestic abuse) can put women at greater risk of psychological ill-health.
Age: nursing, midwifery and paramedic science have ageing populations – this ‘demographic timebomb’
72 means many experienced professionals will be leaving the profession in the coming years.
Ethnicity: there is greater diversity among doctors and nurses than midwives and paramedics. Those with lower diversity have higher vacancy rates.
Service architecture
Turnover and retention remain problematic in all professions.
Nearly half of doctors were consultants, but much smaller proportions of staff held high-grade/band roles in nursing, midwifery and paramedic science.
Salaries were higher for doctors. There are significant gender and ethnicity pay-gaps across all professions.
Well-being
All reported high job stress, particularly midwives and paramedics.
Sickness absence rates for nurses, midwives and paramedics were three times those of doctors, and presenteeism nearly double.
We concluded that sociocultural factors known to increase risk of psychological ill-health may explain some of the differences between professions and that these factors should be considered when designing strategies to improve well-being. Other key recommendations are included at the end of this chapter and in Chapter 7.
Aim (b) to provide a more detailed and nuanced understanding of why psychological ill-health develops in nurses, midwives and paramedics
In this section, we consider each HSE domain in turn, describing the nuanced causes that sit beneath each domain.
Demands
The ‘demand’ causes identified in the literature were analysed and synthesised into nine distinct (albeit overlapping) ‘demands’ that were present across nursing, midwifery and paramedic literature (see Table 6). Unsurprisingly this included the well-reported staff shortages and high attrition in the professions [as reported above, within aim (a)], which could have knock on implications. For example,
Causes of psychological ill-health for nurses, midwives and paramedics
one nursing paper focused on newly qualified nurses73 highlighted that this can mean regularly working with temporary staff (bank or agency staff) and/or being moved to other units (impacting teamwork and collegiality as well as knowledge of the systems and patients), and that such shortages can often mean being the only registered nurse on a shift, leading to feeling “vulnerable, and their units unsafe”73 (p. 3). Another commonly cited demand is having an unmanageable workload, relating to staff shortages and plugging gaps, but also from increased demands for care. This is ‘measured’ more easily in some settings than others, for instance, for paramedics there has been a well-documented increase in call volume over recent years.82,132 In one review, the pressured decision-making and delivery of sometimes complex interventions in this context was cited as a key cause of psychological ill-health.35 In a narrative review of impact of power and hierarchy on staff safety maternity services, one of the key themes was ‘dangerous workloads’ (p. 432) being linked to exhaustion, inflexibility, lack of breaks, low morale, poor communication and poor management.83
Relevant to all three professions is the increasing move to working long shifts (12-hour shifts being increasingly the norm), and these long shifts were reported to often include very few opportunities for breaks (and/or unpredictable break patterns and times). Workplace culture means nursing and midwifery staff ‘tend to miss their breaks because of feelings of guilt, responsibility to colleagues or a sense that they are being most effective if they skip breaks’30 (p. 55). The nature of paramedic work frequently means unpredictable finish times, long hours driving and unpredictable breaks.22 However, the literature reviewed by Ejebu et al.62 suggests nurses often prefer working longer shifts attributing this to a greater work-life balance, higher numbers of days off and opportunities for greater continuity of care. Cull et al.89 found likewise for midwives, though Ejebu et al.62 concluded that despite this the shift patterns were ‘often organised in ways that are detrimental to nurses’ health and well-being, their job performance and the patient care they provide’ (p. 1), reporting that while days off might mitigate the adverse impacts of shift working, the impact varied according to personal characteristics and circumstances of the nurse. Inadequate work-life balance was reported across all three professions, being a key impact on recruitment and retention of community adult nurses in one review60 impacting on family-life in a paramedic review,94 and cited as a key stressor in the Work, Health and Emotional Lives of Midwives (WHELM) report.74 Recent literature tended to focus more on arguing for the need for ‘time’ (for individual self-care and/or family activities), and thereby work-life balance is implied rather than explicit. The culture of ‘serve and sacrifice’ (see Chapter 6) was highlighted within all three professions, described in one midwifery review as a ‘culture of giving 100% … is a positive attribute but can be used negatively to persuade compliance to institutional needs’90 (p. 3), and in a nursing paper as ‘Nursing guidance, policies, reports, the media and nursing colleagues instilled the notion that patients take priority. While this was important for the role of a nurse, it was often interpreted in isolation without consideration of the nurse’s own needs, which were pushed aside in favour of others.’84 (p. 2).
It was perhaps not surprising that repeated exposure to trauma was mentioned in nearly all paramedic papers, but exposure to trauma and distressing incidents was also highlighted in many midwifery and nursing papers, and was the focus of a narrative review regarding secondary traumatic stress (STS) in emergency nurses98 (see Table 6). In one of the paramedic papers this exposure was described as an expected part of the job33 and in another, that there was “no way to avoid seeing sights that are difficult”95 (p. 225). One literature review reported predictors of PTSD, including the frequency and type of trauma exposure (e.g. proximity), and whether the threat to the worker was direct or indirect.21 Arguably a subcomponent of exposure to trauma, although this could also be considered a separate stressor, is ‘experiencing death’ mentioned in papers for all three professions. Again, the impact of ‘death’ is often minimised due to being an expected part of the job and often only acknowledged as requiring support when it is unexpected (e.g. in the case of neonatal death) or particularly traumatic, or in the case of students or newly qualified staff when it may be their first experience of death and so not yet normalised.96,105 The cumulative experience of stress (rather than just acute traumatic episodes), and the emotional labour of healthcare work caused by having to regulate emotions and remain ‘professional’ (called ‘wearing a professional mask’ in our stakeholder group) were cited as causes of psychological ill-health cited within papers across all three professions (see Table 6) and discussed in more detail and with a realist lens in Chapter 6. Some also cited feeling controlled as causal factors of psychological ill-health – both by the ‘politics’ of the organisation in which they worked or the wider healthcare system (i.e. administration, excessive paperwork, bureaucracy, inflexibility), and also by individuals (most often managers): “I felt very much under the control of management”34 (p. 27).
Profession-specific “demand” causes
There were some demand-related causes that were perhaps more profession-specific. One of these was working “on-call” (with unsociable hours), reported in a midwifery paper76 and a review article,77 the latter reporting findings from a Cochrane review of flexible working hours133 that found although negative experiences of ‘on call’ were reported, the midwives who worked on call had lower burnout scores. The authors attributed this to midwives ‘caseloading’, which provided opportunities for continuous care, building relationships with women and having autonomy over their work schedule. On-call working is common in medicine, but across our three professions is more likely in midwifery and – to our knowledge – not a model commonly used in nursing or by paramedics, though the role of the paramedic is rapidly expanding to many settings, including general practice, minor injuries units, and accident and emergency (A&E) departments (#not all paramedics wear green134), where on-call working may be more common. The impact of working ‘unsociable’ hours is relevant across all three professions due to the inherent need for healthcare delivery to be 24/7.
A feature of work highlighted as a cause of psychological ill-health (or at least work stress) was the lack of continuity of knowledge about patients’ health/well-being after being involved in their journey. This was specifically mentioned in a nursing paper about Liaison psychiatric nurses78 but is the nature of the job for paramedics who may care for and transport patients to hospital but not know the patient outcomes beyond this point. One paramedic paper also reported that the high number of unnecessary call-outs they have to respond to as a negative component of work, meaning that they cannot be elsewhere where they may be in greater need.55 Another paramedic paper described “heavy cognitive load” due to the need to make rapid decisions, leading to a reliance on stereotypes and implicit bias,79 which while not mentioned in nursing or midwifery papers, is likely to be similar in other fast-paced ‘critical care’ environments such as labour wards for midwives, and A&E/critical care nursing. Indeed, in a recently published framework of nursing work, cognitive labour is one of four types of nursing work (alongside physical, emotional and organisational labour).135 Paramedic-focused papers referred to feeling physically and emotionally drained because of their working conditions and environment,124,136 and also the high risk of sustaining a work-related injury (e.g. physical or psychological abuse, and concerns about the financial and psychological implications of sustaining an injury).80 One of the nursing papers mentioned the Francis report and nursing being a ‘profession under scrutiny’81 as an aspect of the culture of nursing/health care that places additional pressure on individuals. While not present in any midwifery or paramedic literature in this review, the recent Ockenden review (midwives137) and the media focus on the consequences of growing ambulance waits138,139 makes it unlikely that this is a stressor unique to nurses.
Control
As expected, lack of control or autonomy was a key ‘causal’ factor in many of the included papers across all three professions, with nurses,85 and midwives83 described as experiencing ‘powerlessness’85 (p. 285) and ‘helplessness’83 (p. 432). Autonomy is one of the three core work needs in the ABC framework proposed by Michael West in a report about how to support high-quality care delivery by nurses and midwives.30 When health professionals can control how they spend their time/how much time spent with patients, how they organise or control their workspace, and/or control over access to patients, this in turn can often relate to work satisfaction and staff being able to deliver the quality of care they want to deliver. In one midwifery paper,113 having autonomy regarding how to manage their midwifery unit was highlighted as a key protective factor, supporting earlier work,140 and midwifery papers also highlighted a preference for midwifery-led models of care (where midwives have a caseload of women and can provide continuity of care).86 Across all three professions, the lack of control over working hours and shift patterns was regularly cited as problematic, with papers describing the subsequent impact on friendships, family life and hobbies/interests.30,89,94 There were no profession-specific ‘control or autonomy’ features emergent in the literature.
Support
Not feeling supported and/or valued was a key cause highlighted in papers across all three professions. Lack of support related mostly to poor support from leadership/managers and organisational-level support, with one paramedic paper stating that it was a lack of confidence in support from employers that led paramedics to self-refer to their regulator.114 However, one nursing paper highlighted the lack of support for leaders (senior nurses): ‘(it is) quite lonely at the top when you have no one to speak to’110 (p. 8), and a paramedic paper described the culture as sometimes being unsupportive if a colleague was struggling, referring to the military background of the profession and that there was consequently a very low tolerance for low standards amongst peers.115 In one midwifery paper, midwives described feeling invisible and not being acknowledged,83 and another referred to the harsh mentorship they had received and lack of kindness from managers/mentors,116 with a third describing how midwives felt ‘scrutinised rather than supported by management’89 (p. e553). However, that same paper also describes how midwives in senior positions gain satisfaction from supporting others. Across all three professions, the lack of support when undergoing investigation or complaints processes was also highlighted (see Chapter 6, where this is discussed in more detail).
A relational-cultural cause mentioned in papers across all three professions was the stigma around talking about psychological health difficulties and accessing support. This was particularly prevalent in paramedic papers where it was stated that ‘disclosure of vulnerability in such a culture was perceived as a weakness’ (p. 9) and that the macho culture perpetuated not talking about mental health.18 One paper talked about the bravado or stigma attached with the job ‘we all like to think we are infallible. We are there to support the public in (their) time of need, but we tend to not ask for help ourselves’95 (p. 226). All three professions described their concern that disclosing mental health difficulties may have a negative impact on their careers. One report highlighted that staff were particularly unlikely to access support services if situated in their own place of work and have concerns about confidentiality where staff are unable to self-refer.25 A common theme in the midwifery and paramedic literature (as they were more likely to discuss exposure to trauma) was the lack of space and/or time to debrief after experiencing trauma (or generally having inappropriate support for this). One nursing paper96 described ‘disenfranchised grief’ for the way nurses may be made to feel after the death of a patient – that it was not their ‘place’ to feel loss or to grieve. Together with lack of spaces and/or time, across all three professions the lack of attention paid to basic ‘hygiene’ needs was highlighted (e.g. parking, food, water, bathroom breaks),9,30,34,89 with one report74 stating that this ‘appears to have become an accepted part of everyday practice’.
Profession-specific ‘support’ causes
Lone working was a specific (negative) feature of work mentioned in three nursing papers that focused on specific types of nurses [clinical nurse specialists for chronic conditions;118 emergency nurse practitioners (ENPs) based in minor injuries units;99 and children’s community nurses based in rural or remote areas],119 but this ‘cause’ is also relevant to any nurse, midwife or paramedic that works predominantly on their own (e.g. critical care paramedics who may spend most of their shift in a car on their own except for when attending incidents with other crews on scene; and nurses and midwives in rural/remote areas with a community caseload who may not often see their team members).
Relationships
Having poor relationships with colleagues and/or incivility and bullying was highlighted in papers across all three groups as being a causative factor for psychological ill-health.9,34,83,123 In one midwifery review, they referred to the ‘cultural normalisation of dysfunctional relationships’83 (p. 433) to describe how such relationships have become expected and normalised rather than resolved. Such poor relationships can be within or between staff groups: in the midwifery literature, there was reference to challenges in multiprofessional relationships within teams or clinical areas in particular their relationships with obstetricians,89 as reflected in several high-profile maternity reviews,137,141 and in the nursing literature one paper described tensions between palliative and non-palliative staff.110
Profession-specific ‘relationship’ causes
With regard to relationships with patients, while the nursing and midwifery literature was more likely to refer to the emotional impact of having empathic relationships with patients;100) in the paramedic literature the focus was on fear of assault and/or abuse from the public including physical abuse, intimidation, and sexual harassment. One paper described the physical and emotional stresses being common occupational hazards for paramedics.124 This aspect of work was also reported in a paper focused on nursing in secure forensic units111 and emergency nurses in A&E departments.23
Role
Newly qualified staff were a main ‘at risk’ group, identified particularly in the nursing and midwifery literature. The transition from being a student to being newly qualified is described as a ‘transition shock’ or ‘reality shock’.142,143 One paper73 refers to nurses being uncertain about their competence, unrealistic expectations from managers, and not wanting to make mistakes; and another126 describes feeling unprepared. A related theme in the nursing and midwifery literature is values incongruence (also described as a ‘theory-practice gap’): whereby the work environment does not enable staff to practice how they thought they would and want to.30,75,128 Issues in relation to role boundaries or clarity were mentioned across all three professions, some referring to a lack of understanding of role by others generally (e.g. lack of understanding of nursing work by others;87 unclear boundaries between midwives and colleagues;91 or in relation to particular subspecialisms such as EPNs feeling they had blurred role boundaries with doctors and advanced practitioners;99 prison nurses being a new/young specialty and describe feeling invisible: ‘literally hidden away from the world. This physical “hiddenness” appears to translate into a professional “hiddenness”’52 (p. 163). In the paramedic literature, a conference abstract referred to the conflict that managers feel between their varying roles as ‘manager, clinician, peer, referrer, adjudicator, parent figure, appropriate person and challenger’56 (p. 44), and the tension between performance management and staff support roles. ‘Role intensity’ was described in a nursing-focused literature review130 to capture the stress of work that goes beyond quantitative workload for example, satisfaction with workload, impact of disease acuity. In a blog, one midwife stated: ‘Many times I have cared for someone and thought “this is edging the limits of my training here”’101 (p. 398) describing the intensity caused by increasingly complex care needs due to the changing maternity population (e.g. women having babies later in life, high prevalence of obesity and associated health conditions, and women with more severe pre-existing health conditions having babies). There were no profession-specific ‘role’ causes evident in the literature.
Change
Organisational changes in healthcare provision, and in particular poor management or communication in relation to change – as well as the constant and rapid changes – was a cause of psychological ill-health reported across all three professions. This included the frequent changes in clinical practice reported in neonatal settings, due to medical advances;106 the need for greater involvement in change implementation – particularly in more junior front-line staff – to reduce their sense of ‘powerlessness’ and aid successful implementation of changes in acute mental health wards;78 and for paramedics, the ongoing changes to the scope of their role, and organisational and management changes having key impacts on psychological well-being.22 In the King’s Fund report30 the hierarchical structures in health care were described as inhibiting ‘voice and influence’ (p. 37), and in the WHELM report,74 management were described as making changes as ‘knee jerk reactions to problems’ and ‘not listening to the staff … and valuing the resources that they have in their collective knowledge, skills and care that they give to women and each other’74 (p. 24).
Aim (c) to examine the literature to understand better ‘who’ is at risk and ‘when’ including identifying the differences within and between our three professions of nurses, midwives and paramedics, going beyond demographic and individual characteristics to also consider the impact of different work environments
Who is most at risk?
Individual characteristics
There have been many quantitative observational studies that have attempted to measure risk factors for burnout/psychological ill-health including individual predictors such as demographic factors. Methodological differences in measures and poor-quality studies make these challenging to synthesise, but in general, it is accepted that demographic variables are poor predictors of work-related psychological ill-health.25
The exception to this is ethnicity, sexual orientation and/or gender identity, and disability: there is now increasing evidence, not least from the NHS Staff Survey and recent COVID-19 pandemic, that health-care staff from ethnic minority groups have greater exposure to aspects in their work that place them at greater risk of psychological ill-health. This includes that they are more likely to report experiencing physical and verbal abuse (from patients and relatives, have higher presenteeism rates, and are more likely to report working additional hours, as well as other inequities such as pay and promotion.9,25,93 The Health Education England (HEE) NHS staff and learners’ mental well-being commission9 reported that additional risks for psychological ill-health existed for lesbian, gay, bisexual and transgender/transsexual people (LGBT+) and disabled staff. For staff identifying as LGBT+ the commission reported a wide disparity of experience, with staff in some Trusts facing hostility and discrimination that severely impacted their psychological health, and that many staff hid their sexual orientation for fear of bullying. A specific service architecture feature highlighted was the impact of rotational placements and/or lack of permanent team structure that exists in much healthcare provision, leading to staff having to constantly decide if/when/how to disclose their orientation.9 Disabled staff are also more likely to report bullying/harassment from colleagues than other staff, and in the WHELM report74,128 midwives identifying as having a disability had higher levels of burnout.
Aside from mention in the reports cited above, we found no papers that focused specifically on ethnicity, sexual orientation, gender identity or disability; highlighting a major gap in our understanding of causes and interventions to mitigate psychological ill-health in these staff.
Professions and or subspecialties that may be at greater risk of psychological ill-health
In the included literature, there are several subgroups of the three professions that are presented as being at ‘high risk’. However, it should be noted that there are lots of articles written from the perspective of a particular profession/specialty, making the case for specific challenging features of their profession/specialty (possibly to justify publication), though as can be seen in Table 6, few of the ‘causes’ identified are unique and can be applied across all three professions. Below are some of the role/job related risk factors that have been identified in this review that may be worthy of further attention, particularly in relation to interventions.
Newly qualified nurses/midwives/paramedics
As mentioned earlier in this chapter, various papers discuss the ‘transition’ or ‘reality’ shock of being newly qualified, leaving student status behind and becoming a qualified health professional (see Table 6).90,126 In part this is due to a ‘theory-practice gap’ (see early in chapter and Chapter 6),90,128 as well as a lack of confidence to speak out (when encountering bullying, lack of support, feeling out of control).90 One review describes newly qualified nurses only becoming ‘insiders on the team’ (e.g. accepted/valued) when they are viewed as capable.123 While many articles focused on the ‘newly’ qualified (first year or two of practice), evidence suggested that risks of psychological ill-health associated with being ‘less experienced’ continue for up to 10 years from qualification.77
Location: hospital versus community
There was a suggestion in some of the literature that working within a hospital setting placed staff at greater risk of bullying, harassment and abuse,76 but this contrasted with other literature that highlighted the social and professional isolation that professionals in the community may experience together with the distinct environmental risks from providing care in the home or other non-clinical environments such as schools and thereby having fewer safeguards in place.97,119
Being a ‘leader’
The issue of managers requiring support as well as undertaking the role of providing support was highlighted in a few papers.110
Working in an ‘orphan’ specialty (distinct, young or neglected)
There were several papers focused on individual specialties that highlighted the distinct nature of their work and often their feelings of ‘invisibility’, where there has perhaps been less research or policy attention. This included district nurses97 and children’s community nurses in rural/remote areas.119 There are also ‘new’ professions (including paramedic science, existing since the 1970s) or distinct subspecialties, such as prison nursing, where there has been much less research. Prison nursing has various unique features, not least the need to balance caring versus custody, lack of understanding of the role by others, and poor visibility of the profession both within nursing and to the wider public.52 There are likely to be other such ‘orphan’ subspecialties omitted from the literature, and a gap-analysis should be undertaken to inform future research regarding causes and interventions.
Working with a ‘high-risk’ patient group
Several patient groups were positioned as being particularly ‘high risk’ in relation to causing stress and psychological ill-health. This included the following:
adult critical care nursing144 and
end of life care:
96 due to the emotional toll of exposure to death.
paediatric versus adult nursing: evidence here was conflicting, but several papers described the greater impact of paediatric care. For example, one paramedic paper describing a failed resuscitation attempt on a child saying ‘
certain calls would affect me more than others’;
95 and a nursing literature review
93 describe paediatric nursing as positioning nurses at greater risk due to the high potential for empathic engagement and complexities in relationships with families
93 and a review of neonatal nursing also describing this emotional labour as being a key part of what makes it a higher risk environment to work in
106 due to advances in medicine leading to longer hospital stays (greater emotional support for parents) and more ethical dilemmas relating to end of life care resulting in MD.
Mental health nursing: papers focused on nursing in mental health inpatient settings describe the volatile, fluctuating environments with highly distressed patients as distinct stressors
73,85 and thereby higher risk of psychological-ill health. One paper focused on burnout in high secure forensic psychiatric units, found rates to be comparable or lower than community or non-secure mental health nurses,
145 suggesting perhaps that it is less about patient acuity and more about environmental factors linked to staff safety and support. However, a review of nursing in secure forensic mental health settings highlighted a unique feature of the environment relating to ‘gender and sexuality’: that although locked wards were single-sex, they had both male and female staff, which can sometimes leave female staff feeling vulnerable and marginalised.
111 Liaison psychiatric nurses
78 may also have distinct features that place them at risk due to exposure to people with high levels of distress in the context of pressure for quick turnaround, multiple interfaces, liaison with gatekeepers, and little or no continuity after discharge.
Chronic illness: nursing provision for patients with chronic illness (e.g. inflammatory bowel disease
118) was identified as a risk factor due to the increasing complexity of the treatment and management of patients, the emotional labour of the long-term relationship with patients, and lone working if they are the only specialist nurse in the hospital/setting.
emergency nurse practitioners: risk factors include
99 exposure to trauma, not being taught to deal with death (unlike doctors), blurred role boundaries and identity and being expected to practice beyond their scope. ENPs may also feel geographically isolated if they work in a minor injuries unit that are distant from a hospital.
