Published 22 October 2020
Intensive care as a positive place to work
Last week were released our Intensive Care as a Positive Place to work: Workforce Wellbeing Best Practice Framework. This work, led by the Intensive Society, is a collaborative between intensive-care organisations. We have worked to bring together the strongest evidence base, including practice-based examples.
Writing a framework such as this proves challenging; it is important to consider it as aspirational, and as a starting point that we can review over time. It is also very difficult to produce a framework when we are in the middle of one of the biggest challenges to intensive care, the NHS and society as a whole has had to endure. During this pandemic, some of the fundamental things we require to ensure intensive care is a safe and satisfying place to work have been compromised: in some areas staffing ratios have been stretched, shift patterns have been gruelling, the environment has been pushed to and beyond its limits. Some would argue it is hard to consider what is possible now, versus what is possible when our status quo returns, if it ever does.
However, there are some core fundamentals which we should still aim to apply whether we are in a pandemic or not. These are:
- We need to be primary preventative in our focus and consider the core conditions for a safe and satisfying place to work, as well as being able to access those interventions targeted during or following problems (secondary and tertiary interventions). Recommendations 2-8 are primary preventative.
- Leadership is fundamental to people’s experience of work and is one of the biggest predictors of staff experience and wellbeing.
- Staff need clear communication and opportunities to feel engaged with the work.
- How the job is designed & access to job related resources (especially staffing) impacts people’s ability to care for patients and therefore staff wellbeing.
- Access to education and opportunities for progression improve people’s experience of work, sense of purpose and development.
- A safe and fit for purpose physical environment is essential. This should include both, sufficient facilities for staff and infrastructure for patient care.
- Relationships with peers and unit culture (or “how we do things around here”) should be shaped by leaders.
- The general wellbeing of staff should be routinely monitored and measured.
- We need different ways of mediating the staff stress response, through understanding this at all levels, to offer formal and informal spaces for staff to talk and make sense of their experience.
- Access to professional psychological support, to provide evidence based 1-1 psychological therapy is important in helping people restore and recover from the emotional impact of the work.
You will note the guidance advocates for the core conditions of managing workforce wellbeing in intensive care as a whole. This goes beyond the management of stress and emotions of work. It is not something provided by one person, or by one intervention, it is a whole system responsibility. We need to move away from the focus on individualistic and tertiary intervention approaches. Interest in workforce wellbeing surged post-2013 Francis Inquiry[i]. The inquiry linked patient errors and deaths to toxic culture and dysfunctional leadership; and it was concluded that to mitigate the risk the NHS needed to move towards a culture of compassion. This sentiment was echoed by the 2013 Berwick report [ii].
In 2014, the Care Quality Commission (CQC) in England took this into account by shifting towards considering staff wellbeing and staff engagement in their assessment. This led to an increased rollout of employee wellbeing initiatives, but mostly focussing on individual approaches to self-care and self-management[iii].
Thankfully, many important papers and guidance have sought to rectify this individualistic approach. For instance, the 2015 NICE Workplace Health: management practices[iv] recommendations focus on leadership competencies & practice for the wellbeing of the workforce. The 2017 British Psychological Society paper, Psychology at Work emphasised the need for us to focus on the psychosocial working environment[v]. The Health Education England commissioned document, Workforce Stress and the Supportive Organisation takes a systemic approach to workforce wellbeing[vi]. More recently in 2019 and 2020, reports on the mental health of nurses and midwives[vii], and of doctors[viii] have emphasized the need for improving the core conditions of work to improve staff wellbeing and patient outcomes.
Ensuring our intensive care is a positive place to work is everyone’s responsibility and is not created through one-off initiatives, but by the continued efforts of all staff. We need to shift the focus from short-term ‘dressings’ for workforce wellbeing, to a sustainable full-system change.
Dr Julie Highfield
ICS National Director for Wellbeing