A Review of "Care Under Pressure"

Healthy staff are necessary for excellent patient care – a key finding of this paper, and one that explains its place in this edition of the CAI’s Quality & Safety newsletter. Care Under Pressure (C.U.P.), the UK-based research group that authored ‘Optimising strategies to address mental ill-health in doctors and medical students: ‘Care Under Pressure’ realist review and implementation guidance’, has members from diverse research and clinical backgrounds. C.U.P. included 179 records in a realist review which was conducted with the aim of “improving understanding of how, why and in what contexts mental health services and support interventions can be designed in order to minimize the incidence of doctors’ and medicals students’ mental ill-health.”1 A realist literature review is a strategy for synthesising evidence, with an aim of providing explanations for why interventions may or may not work, in what contexts, how and in what circumstances.2 It was developed in the early 21st century as a means to evaluate evidence for the efficacy of interventions in a clinical context – “The aim is to enable decision-makers to reach a deeper understanding of the intervention and how it can be made to work most effectively. Realist review does not provide simple answers to complex questions. It will not tell policy-makers or managers whether something works or not, but will provide the policy and practice community with the kind of rich, detailed and highly practical understanding of complex social interventions which is likely to be of much more use to them when planning and implementing programmes.”3 Consequently, this paper does not provide simple answers such as ‘intervention X provides the solution for problem Y’, rather it shines the light down the pathway and allows us to make our own evaluation of whether we are making the most effective efforts to support the mental health of our colleagues. The key points extrapolated in this realist review were the explanation of mechanisms that cause mental ill-health, as well as identification of the contexts in which those mechanisms are likely to be triggered; with a synopsis of the factors that improve the likelihood of success of interventions to prevent or help mental ill-health. These were structured around four main categories: 1) Processes leading to mental ill-health: isolation; 2) reducing mental ill-health: groups, belonging and relationality; 3) reducing mental ill-health: balance and timeliness; 4) implementation methods: engendering trust. The key points are illustrated in Figure 2. Processes leading to mental ill-health: isolation Feeling isolated, unable to perform their allocated role and fearing repercussions in the event of seeking help all increase likelihood of doctors experiencing mental ill-health. The authors found that both organizational factors (such as workload/ work structure/ workforce planning and governance) and work culture (including ideas of invulnerability, perfectionism, stigma around mental ill-health) intertwined with external factors such as predisposition to mental ill-health, personal contexts or traumatic events outside of work to increase likelihood of mental ill-health. Reducing mental ill-health: groups, belonging and relationality Improved workplace cultures and wellbeing promotion is more likely with interventions that emphasise relationships and belonging. The authors found that doctors with a workplace that fostered a sense of belonging and had meaningful workplace relations had an increased capacity to work under pressure. Relationships that occur spontaneously are particularly positive and are more likely to happen in a work environment that has protected time and space for doctors/ medical students to congregate. These might include a comfortable staff room or ‘Res’. Conversely, one-to-one approaches are proven to be particularly beneficial in specific circumstances, for example if individual is under investigation or after the death of a colleague. Reducing mental ill-health: balance and timeliness This review found that a balanced approach to feedback and support among doctors was beneficial; open acknowledgement of both the rewarding and stressful aspects of medicine as a career can lead to doctors thriving at work and improved ability to deal with work pressures. Supervision, feedback and learning practices that recognize both positive and negative performance can lead to improved connectedness and engagement in the workplace, and to a more supportive work culture. We are all familiar with being involved with an adverse event that is followed by deafening silence – fostering a culture where mistakes, poor outcomes and poor performance are discussed in an open, non-judgmental way would be beneficial for the reasons outlined above. Working towards a workplace culture that the promotes health and wellbeing, as well as focusing on fighting mental ill-health, can contribute to the normalization and de-stigmatisation of mental ill-health. Implementation methods: engendering trust This paper provides some important guiding principles to consider when implementing an intervention to either promote mental health or to tackle mental ill-health. How interventions are implemented appears to be as important as the intervention itself. Effectiveness depends on doctors’ confidence in the persons delivering the intervention; interestingly, endorsement by senior management improves the efficacy of an intervention. Involving the doctors themselves in the design improves the outcomes of interventions, perhaps by fostering a sense of community and ownership of the measures taken to prevent mental ill-health. This ties in with the findings that in the setting of meaningful workplace relations and functional working groups, it is possible for doctors to have a sense of belonging and an ease with vulnerability. This ease with vulnerability is important as it ties back to reduction of isolation as a means of reduction of mental ill-health. The research group developed ten ‘Care under Pressure’ principles, to guide introduction (or refinement) of mental ill-health prevention or wellbeing promotion interventions. We have outlined these in Figure 1. This article is a good resource for those who may be heads of department, or have a wellness remit/ portfolio within their department, or simply those who may be introducing positive change within their department. Of note, much of the focus in Irish anaesthetic circles has been on wellness issues for trainees – when of course these issues can affect medical students and doctors at any stage of their career.

Figure 1. ‘Care under Pressure’ principles to guide introduction of wellbeing and mental ill-health interventions

Bottom Line This paper is worth reading for anyone with an interest in ensuring that their workplace is as safe as it can be for both staff and patients. The Care under Pressure group have cartoon resources (such as the one in the banner) and updates freely available from https://sites.exeter.ac.uk/cup/. We have synopsized the key learning points of the article in the printable poster below (Figure 2), which is designed for colour printing in A3 size ideally. It may act as a reminder to avoid the triggers of mental ill-health or a prompt to ensure optimum positive interventions in any anaesthetic department

Figure 2. Poster for printing graphically outlining key points of Optimising Strategies to address mental ill-health in doctors.

References: 1. Optimising strategies to address mental ill-health in doctors and medical students: ‘Care Under Pressure’ realist review and implementation guidance. Carrieri, D., Mattick, K., Pearson, M. et al. BMC Med 18, 76 (2020). https://doi.org/10.1186/s12916-020-01532-x 2. Rycroft-Malone, J., McCormack, B., Hutchinson, A.M. et al. Realist synthesis: illustrating the method for implementation research. Implementation Sci 7, 33 (2012). https://doi.org/10.1186/1748-5908-7-33 3. Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review-a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy. 2005 Jul;10 Suppl 1:21-34. doi: 10.1258/1355819054308530. PMID: 16053581.

Dr. Tara Feeley
Fellow in Paediatric Anaesthesia, Starship Hospital, Auckland, New Zealand