The Government has recognised that NHS staff working in clinical environments must be supported emotionally. Those who deliver direct care to patients may absorb and experience some of their patients' emotions, including fear and sadness. The empathetic traits common among nurses and other care workers can negatively impact their own emotional health.
Background
One year ago, NHS Employers launched its ‘How are you feeling today NHS?’ initiative (NHS Employers, 2019). This easy-to-use resource was designed and developed with the help of NHS staff to promote greater awareness of emotional health in frontline care workers. This tool enables nurses and others to discuss emotional health more openly and can help assess the impact emotional wellbeing has on staff members and their patients.
The past 12 months has seen society as a whole talking much more frankly about mental health, helped by the Duke of Sussex, who has led a high-profile campaign to bring mental health into the limelight (Booth, 2017).
Stress and burnout among nursing staff has been a feature of the profession since its inception. Readers of a certain age will no doubt remember as student nurses encountering fearsome ward sisters. I remember one such ward sister, and in those days there was usually only one per 30-bed ward, who in a temper used to hurl hardback fluid balance chart holders at students if they wrongly calculated patient input and output! Today such actions would not be tolerated, but perhaps would be recognised as a sign of stress and burnout. Many nurses practice in very emotionally challenging environments.
It is widely believed that Florence Nightingale suffered significant emotional trauma during the period she spent at the Scutari hospital during the Crimean war. As the leader of the nursing teams at this military hospital, the amount of stress she would have had to endure must have been considerable, as is probably true of any nurse working within a war zone. When Nightingale returned to England, she experienced illness, exhaustion and depression (Mackowiak and Batten, 2008).
Stress and burnout
The high level of stress experienced by nurses can lead to burnout and a host of detrimental effects. It is now recognised that greater support is needed for those who deliver frontline care. Many care staff in the NHS witness scenes of extreme emotional distress, such as caring for a patient dying prematurely in an intensive care unit, and then helping a distraught family in their bereavement. The ability of these staff members to cope with these emotional encounters must not be taken for granted and many frontline clinical nurses who are exposed day after day to such emotional stress need help and support. This is crucial to prevent them from reacting in ways that are damaging to their own health and which can subsequently lead to burnout. This in turn can cause emotional exhaustion, depression and a reduction in performance in the workplace.
Preventing burnout among nursing staff can reduce preventable serious incidents in practice (Kowalski et al, 2010). The wellbeing of these nurses must be optimised if the delivery of positive patient care is to be achieved throughout the service.
Burnout among care staff has not only been widely recognised and reported but knows no geographical boundaries. The reports of exhausted, stressed doctors and nurses working in China during the current coronavirus outbreak exemplify this (Standaert, 2020).
There is a vast amount of worldwide literature on burnout in the nursing profession. For example, in a study of 895 South African nurses Khamisa et al (2017) studied the relationships between work-related stress, burnout, job satisfaction and general health. Of the five stressors they identified as contributing to work-related stress, staffing issues were found to be most associated with burnout.
Rushton et al (2015) conducted a survey of 114 nurses working in six intensive care units in the USA in which they assessed factors associated with burnout, moral distress, and resilience. Greater resilience seemed to protect nurses from emotional exhaustion and these higher levels of resilience were associated with increased hope and reduced stress and contributed to personal accomplishment. Similarly, spiritual wellbeing was linked with reduced emotional exhaustion
In a systematic review of the literature, van Mol et al (2015) endeavoured to evaluate the research related to emotional distress among health professionals in intensive care units with a specific objective of illuminating the prevalence of burnout and compassion fatigue and the use of available preventive strategies. From the literature reviewed they found that there was a range of intervention strategies available to address burnout, such as different work schedules, educational programmes on coping with emotional distress, improving communication skills, and relaxation methods.
An Italian study aimed to estimate the level of burnout among 100 Italian oncology nurses (Quattrin et al, 2006). The researchers were especially interested in identifying the risk factors for burnout and the strategies used to prevent and deal with stress. A significant finding was that an important cause of stress reported by nurses was poor organisation. In light of this finding the authors suggest that hospitals should focus attention on addressing those organisational deficits which exacerbate emotional distress among nursing staff and develop policies that aim to tackle burnout.
Given the volume of evidence that burnout among nurses can be successfully addressed, it is salutary to consider why strategies to prevent it have not been implemented. Nurses are expensive to train and retain and every effort should now be made to support those who develop mental health problems as a result of psychological pressures at work.
Currently, plans are being developed to help ameliorate stress within the NHS workforce by giving nursing staff and others immediate access to dedicated mental health support when they need it. Health Education England has commissioned a framework to help NHS organisations be more supportive (National Worforce Skills Development Unit, 2019).
To help prevent burnout among its staff, one hospital has announced that it has invested in sleep pods to allow tired staff members such as doctors to have power naps. Such initiatives are to be applauded (Thomas, 2019).
NHS Employers' emotional wellbeing toolkit
Launched in January 2019 the How are you feeling NHS toolkit has been designed to help NHS staff reflect on and discuss the emotional wellbeing of themselves and others within the care team. This easy-to-use resource (https://tinyurl.com/wt5oamk) has been developed with NHS staff to:
NHS staff who helped design the toolkit identified that emotional wellbeing can be explained in three ways. Individual staff members such as nurses may be:
The toolkit asks users to identify which of the three options best describes their current emotional state. I personally tried it out and opted for ‘on the edge’. I found the many options offered did actually describe how a nurse having a very bad day would feel in that situation, such as ‘You seem to have too much to do and not enough time in which to do it.’
The toolkit identifies the probable causes of their feelings and then describes the impact of that emotional state on others. For example their colleagues may see them as: angry, unsupportive, prone to make mistakes, defensive, inconsistent and easily distracted.
The final part of the survey offers the nurse a range of actions that might improve the situation, such as ‘Take time to re-energise yourself—do something that you find enjoyable, relaxing and which takes your mind off work.’.
Conclusion
In contemporary health care, it is vital that care staff are supported emotionally and that employers have the right procedures in place to offer them help when they need it. Good employers are taking the emotional health of their staff very seriously and the ongoing use of the ‘How are you feeling NHS?’ emotional wellbeing toolkit is to be recommended.