Introduction

As with many areas of the NHS, staff working in paediatric critical care (PCC) settings face immense pressures. Some studies suggest they have high rates of burnout and compassion fatigue compared to other specialities - see here (1) and here (2).

Research to date has concentrated on quantitative surveys and has primarily focused on measuring burnout and compassion fatigue (1, 3). While these are important to explore and study, there is a paucity of qualitative research exploring the challenges that staff working in PCC face.

It is crucial that potential interventions are also considered, and to focus on what wellbeing means to staff if we are to support them. It is also critical to understand what life events staff have experienced that have challenged their wellbeing, in order to see what has helped and hindered them.

Areas studied

In 2020, Birmingham Children's Hospital (BCH) charity funded an 18-month project into staff wellbeing on paediatric critical care. Its aim was threefold:

• to audit current interventions and analyse their psychological bases
• to understand what wellbeing means to staff in PCC
• to understand staff experiences of times when their own wellbeing was challenged and examine what helped and hindered them in these situations.

All medical and nursing staff at BCH PCC were invited to take part in an in-depth interview (aim 3) led by a researcher independent of their unit, with 53 subsequently participating. It became clear that taking part in these interviews acted as an intervention in its own right, as staff were able to focus on, identify, and make sense of challenges to their wellbeing and explore how they might prepare for similar events in the future.

This instigated a small shift in culture, with many staff experiencing the benefits of reflective conversations about their wellbeing. This opened their eyes to the possibility of psychologically safe spaces to help them process challenges.

What areas do people report as challenges?

In our single site project, staff identified 15 stressors, which were collated into the themes summarised below. These included the impact of COVID 19, the role of leadership, medical events having unexpected outcomes, patient deaths, working patterns, personal life events, physical facilities for PCC staff and teamwork.

Staff were asked to describe the situation from which the stressor arose, how it helped and hindered their wellbeing, and to identify what might help in the future.

How have these challenges to wellbeing changed over the last few years?

In our single site, one pertinent finding participants identified was that their PCC patient group had significantly changed in the last ten years. This is in line with data produced globally (5, 6, 7, 8) evidencing that who is being admitted to PCC units has changed.

Data produced by PICAnet showed that 10% of children admitted to Paediatric Intensive care used over 50% of PCC unit resources. This is crucial to note, as in the future there is likely to be an increased demand for PCC from children who have life-limiting conditions but are surviving longer due to medical advances.

Nursing and medical staff in our study said that the number of long-term chronic complex patients has increased in the last ten years, and staff also observed a shift in attitude to medical and nursing staff, with parents and care givers expecting more. For example, family members may try to control when lights go on and off and which staff members they would like to look after their child. Staff said this is emotionally and physically exhausting.

Staff also lacked basic needs for themselves, with changes in the provision of food during night shifts and on weekends - for example, hospital canteens not being open during these hours.

What keeps people going?

Teamwork, good leadership and having basic needs met were unanimously identified as essential for optimal wellbeing (4, 9). Staff recognised the power of good teamwork, clear communication, having leaders who were visibly present on the clinical ward and were approachable. Junior staff commented on the positive impact that having senior staff educate and teach them had on their clinical practice.

Good leadership was notably a factor that staff appreciated and recognised as important in maintaining wellbeing. Doctors and nurses in this study did not have excessive wishes or wants, but commented on the importance of having their basic needs met; as well as having access to hot food at the weekends, they requested access to safe parking and somewhere accessible to rest during a shift. 

The findings from this single site project were echoed in smaller research conducted in PCC units across the UK (10, 11), where PCC medical consultants identified the following as significant to their wellbeing:

• positive and negative impact of working during COVID-19
• job satisfaction and public scrutiny in the unique environment of PCC
• supporting the workforce through modified shift work
• perceptions of support and recognition offered from the hospital management
• successful coping strategies, civility and good teamwork.

What can employers do?

There is now a critical need for organisations (12), including individual NHS Trusts and Health Boards, to support staff at work in a holistic manner. In particular, research (13) has focused on recommendations for staff who have been involved in workplace violence, and has examined the impact of a second victim peer support programme (14).

NHS Trusts/Health Boards need to actively listen to expert advice and review the evidence when considering wellbeing offers to employees. Wellbeing support should be offered to all staff, regardless of medical speciality, in a meaningful and supportive way; Birmingham Children's Hospital has adopted the pyramid approach shown below (15).

The tailoring of support needs to consider individual circumstances, but also the level of intervention required. We should be offering multi-layered wellbeing interventions and creating psychologically informed environments.

We also recommend NHS Trust/Health Boards should be seeking to provide universal wellbeing support - the bottom of the pyramid - for all staff, through which it is possible to create a wellbeing-supportive workplace culture. Targeted support may be offered to staff groups at specific times or on request, but should reflect the need for particular kinds of support in particular situations.

At the top of the pyramid, we see clinical treatment and interventions reserved for those experiencing psychological distress, either as an acute response to an event or due to longer term burnout or other mental health issues.

Employers should interact with staff using the approaches that staff value, as found in our research (9, 10). The focus should be on building a resilient system that cares for individual staff and teams when they are going through challenges to their wellbeing.

Conclusion

While our research is potentially limited in scope, because we worked largely in one PCC unit in the UK, our findings did resonate with national studies (10, 11, 16).

Going forward, meaningful wellbeing should remain in the agenda across all medical specialities. Trusts and Health Boards must work with other organisations, as well as individual HR departments, to ensure all staff feel valued and supported at work, regardless of what challenges they may be facing. Failing to keep staff wellbeing a priority could have wide reaching consequences for the NHS.

The views expressed in this article are those of the authors and do not necessarily reflect those of the MDU.

Further reading:

• "It's been years and it still hurts": Paediatric Critical Care staff experiences of being involved in serious investigations at work: a qualitative study - Intensive Care Medicine – Paediatric and Neonatal (springer.com)
• Managing well-being in paediatric critical care: a multi-perspective qualitative study of nurses' and allied health professionals' experiences - BMJ Open