It is well recognised that emergency medicine staff are exposed to stressful situations on a daily basis (Burbeck et al, 2002; García-Izquierdo and Ríos-Rísuez, 2012; Kessler et al, 2015; McAleese et al, 2016; Somville et al, 2016). The psychological impact of occupational stressors has been widely acknowledged within other professions such as the fire, police and military services. However, despite being identified as a high-risk occupation, few studies have examined the prevalence and impact of mental health issues among staff in the emergency department (ED) (McAleese et al, 2016; Morrison and Joy, 2016; Glasper, 2020; Ratrout and Hamdan-Mansour, 2020).
The current coronavirus pandemic increases the risk of work-related stress and presents challenges for all NHS workers never experienced before, being described as the ‘perfect storm’ for potential stress-related illness for healthcare staff (Khajuri 2020). A cross-sectional study undertaken in China identified mental health distress among front-line healthcare workers, particularly nurses, and emphasised the need for psychological intervention (Lai et al, 2020).
In the NHS there is no official training in place for clinical staff to support their colleagues following a traumatic patient case. ED staff are trained to deal with the technical aspects of their role, but less prepared to manage the psychological effects. (Minnie et al, 2015). Within the hospital that was the site of this study, health professionals are gathered together following a traumatic case for a ‘hot debrief’ led by the senior clinician. Debriefing following a traumatic clinical case is a recommended intervention to improve clinical performance (Bhanji et al, 2015). Moreover, debriefing can identify areas of optimal and suboptimal performance (Zinns et al, 2015). However, this type of debrief is primarily focused on performance rather than staff support (Kessler et al, 2015). Should any member of staff be emotionally affected by a case, then their manager can refer them or they can self-refer to the organisation's occupational health service. A consequence of this unstructured approach is that the delivery of emotional support can be unplanned, dependent on clinical lead and frequently not offered.
There has been considerable debate over the role of early psychological support, for instance Critical Incident Stress Debriefing (CISD) (Mitchell and Everly, 1995). This can be best described as a supportive crisis discussion following an event but has become subject to scrutiny, as outlined in Box 1.
Box 1.Arguments against Critical Incident Stress Debriefing (CISD)
- The limitation of a one-off debrief session. This is considered inadequate for dealing with the psychological impact of traumatic exposure (van Emmerik et al, 2002; Rose et al, 2002; Regel, 2007)
- Although it is worth noting that the research casting doubt on effectiveness of CISD is now considered dated (Burchill, 2019), research has indicated that at a minimum CISD is not helpful in decreasing the effects of traumatic exposure (van Emmerik et al, 2002; Rose et al, 2002; Bledson, 2003; World Health Organization (WHO), 2012)
- Some research has raised the suggestion that the one-off debrief model can even contribute to the symptoms of post-traumatic stress disorder (Bledson, 2003; WHO, 2012). Briefly, people may be using avoidance coping strategies after stress. Asking them to address the issue, however, is asking them to re-live it, which could trigger a past traumatic experience
- There is insufficient training and experience for clinicians in how to conduct a debrief (Kessler et al, 2015)
- CISD may be too brief, timing can be too soon after the event, and concerns have been raised that the debrief can be too mentally invasive (Hawker et al, 2011; Sandhu et al, 2014)
Research in favour of CISD suggests that, if performed by an appropriately trained facilitator, it could reduce the risk of post-traumatic stress disorder (PTSD) (Boscarino et al, 2005). Clark et al (2019) further suggested that the use of CISD is an opportunity for ‘clearing the air’, to ‘ask questions’ and receive ‘positive reinforcement’. Overall, the efficacy of CISD is still debated and the World Health Organization (2012) recommends that immediate psychological debriefing should not be used as an intervention to reduce PTSD, anxiety or depression. Box 1 summarises the arguments made against CISD.
What is PACE?
Peer Assessment after Clinical Exposure (PACE) is a non-judgemental, confidential and supportive programme that supports staff in the immediate aftermath of an incident by an ‘event diffusion’ (previously referred to as hot debrief) led by the senior clinician. All staff are offered a ‘pause’ and then reconvene a few minutes later as a group. The event diffusion is a fact-based summary of the patient case. It is followed up 72 hours later (senior clinicians included) by a one-to-one assessment from a PACE facilitator, and then a PACE follow-up took place 4 weeks after the assessment. PACE is also available for staff who are experiencing cumulative stress as opposed to a one-off traumatic stressor (Figure 1).
Figure 1. Structure of the PACE programme
A course was developed to train the senior medical (ST3 to consultant level) and senior nursing (band 6 to matron) ED team in how to conduct an event diffusion to support staff clinically, and then to address the emotional needs of the team by recognising the signs and symptoms of acute and chronic stress. Research for the course originated from the military ‘TRiM’ (Trauma Risk Management) course (Greenberg et al, 2008), and other resources surrounding traumatic exposure were also utilised. All content and literature of the PACE course was supervised by a clinical psychologist in psychological trauma and a chartered member of the British Psychological Society.
The PACE facilitator works within the strict protocol boundaries of the programme. Their role is to listen and signpost individuals for further support where or if necessary. Staff members who engage in the PACE programme are offered their first peer assessment at 72 hours following the clinical exposure and then again at 4 weeks. This is in line with National Institute for Health and Care Excellence (NICE) (2018) recommendations for the assessment of traumatic exposure symptoms.
A psychoeducational stress reaction support leaflet is also provided. If a one-off incident has not occurred but a staff member requests a PACE for cumulative stress they can access their first peer review assessment at any time and are still to be followed up 4 weeks later.
The PACE facilitator is trained in the use of an adapted version of the Secondary Trauma Support Scale developed by Bride et al (2004) (permission given). This is a short, validated questionnaire that has been used as a tool to evaluate the impact of stressful exposure. It is a 17-item instrument designed to measure intrusion, avoidance and arousal symptoms (Bride et al, 2004) and is used at the 72-hour and 4-week stages.
The overall purpose of PACE is to support staff by building psychological resilience through awareness-raising about what constitutes ‘normal stress reactions’ and signposting individuals to the occupational health service if they are showing signs of acute stress reaction or particularly struggling following an event and would like further support. Furthermore, it identifies individuals who may be experiencing particularly high levels of cumulative stress so that appropriate support can be offered quickly and responsively.
A team of 10 senior staff were trained in the PACE programme and the pilot service was implemented within the ED.
Aim
This qualitative study is part of a service evaluation to explore the thoughts and experiences of the staff who accessed the PACE programme. Information was gathered and analysed over a 6-month time frame (September 2016 to March 2017)
Ethics
The study was awarded full ethical approval as part of a service evaluation through the research department based within the North West England hospital where the pilot programme took place. All procedures prescribed were adhered to, including the provision of clear information for all participants. Consent had been obtained prior to the case that triggered the individual's use of the PACE service.
Methods
A study information leaflet was distributed via email and letter to all clinical staff within the ED. Individuals then had the opportunity to register their interest to partake in the service evaluation over a 2-week period. A non-probability convenience sample was used where the first two participants were selected from each professional group. This was to ensure that the feedback represented the cross-section of professionals who worked in the ED. In all, 12 candidates participated in the study (see Table 1 and Table 2 for details of cohort and demographic data).
Table 1. Participant and professional roles
| ED01 | Band 5 staff nurse |
| ED02 | Senior sister/team leader |
| ED03 | Band 6 staff nurse |
| ED04 | Band 5 staff nurse |
| ED05 | Emergency nurse practitioner |
| ED06 | Senior ED specialist trainee |
| ED07 | Emergency nurse practitioner |
| ED08 | Consultant in ED |
| ED09 | Advanced nurse practitioner |
| ED10 | ED specialist trainee (on rotation) |
| ED11 | Consultant in ED |
| ED12 | ED specialist trainee (on rotation) |
Table 2. Demographic information of participants (n=12)
| Demographic information | Mean (SD) |
|---|---|
| Age (years) | 40.5 (10.75) |
| Female | 8 (66%) |
| Years' experience | 13.6 (9.63) |
| Hours worked per week | 36 (5.33) |
At 5 weeks from their last assessment the participant was invited for an interview, where five open questions were asked to initiate a discussion over their PACE experience (Table 3). The researcher conducted the interviews, but the PACE assessments at 72 hours and 4 weeks were performed by the trained facilitators within the department.
Table 3. Research interview schedule
|
Data analysis
Interpretative phenomenological analysis (Smith et al, 2009) was adopted to explore the individual experience of PACE and to analyse the data. Interviews with the 12 participants were audiotaped and transcribed. Each individual transcript was then revisited to identify statements relating to the phenomenon being explored and from these emerging themes developed. Connections between the themes were then established. These themes were then categorised into superordinate themes and were supported by subordinate themes, which in turn encapsulated the participants' experience of PACE.
Results
Four superordinate themes developed within the data and each theme were supported by subordinate themes. The themes were identified chronologically and inadvertently created a reflection of work life in ED before and after PACE (see Figure 2).
Figure 2. Superordinate and subordinate themes pre and post PACE sessions
Context
Context became the first emerging superordinate theme and included the subordinate themes of: work environment, perception of professional role, previous support experience and emotions.
Work environment
All of the candidates interviewed identified that ED was a busy, crowded and stressful environment to work in, stating that ‘the workload is incredible’ (ED01), and that time was always a pressure:
‘The pace is so fast, I have to make clinical decisions in no time at all and this stresses me.’
ED10
Limited resources were identified as a further contributing factor to the stressful environment:
‘Crowding and lack of resources makes my job very difficult.’
ED11
‘Lack of space and patients needing beds, seeing frail patients in the corridors waiting for trolleys, that causes distress.’
ED02
Perception of the professional role
Five of the participants stated that working in the ED was not a ‘normal job’, suggesting that it takes a particular type of person to cope with the demands of this professional environment. For example, one participant explained
‘This is not an office 9 to 5, we are dealing with people and it literally is life and death at times.’
ED03
Previous support experience
Spontaneously, eight out of 12 participants referred to being involved in a previous stressful or traumatic situation and not receiving any form of emotional support. A junior staff nurse volunteered that:
‘I know the work, but sometimes the things you see—nothing prepares you for that.’
ED01
An ED consultant shared:
‘It is grim when you are not supported, I was involved in a paediatric arrest and not one person asked if I was OK.’
ED11
However, two out of the eight participants (senior medical candidates) did not have a problem with not being supported. For example, one stated: ‘I have my own coping strategies’ (ED06), appearing unaffected by the lack of support.
Emotions
The majority of participants (9/12) felt that there was an expectation ‘just to get on with it’, but all participants discussed human factors interfering with this notion, commenting ‘we are not machines’ (ED04). Additionally, nine of 12 participants identified ‘crying’ as emotion that lacked ‘professionalism’. The phrase ‘you have to hold it together’ was shared by six of the participants, suggesting that it is necessary to keep control of emotions in order to remain professional.
‘Crying is seen as weakness, it looks like you can't cope.’
ED 07
Similar phrases were used to describe the nursing and medical leadership role in particular as one needing the holder to be above emotion, as ‘you have to steer the ship’ (ED05).
Pre-PACE experience
The next superordinate theme of experience before the PACE programme contained the subordinate themes of: perception of stress, individual stressors, and coping strategies.
Perception of stress
Three participants referred to paediatric resuscitation cases as being the most traumatic, for example:
‘Think of clinically caring for a child, then the child dies, it is so traumatic.’
ED10
Although the resuscitation cases were identified as critical and traumatic, the participants also recognised that many other aspects of the job, including interactions with relatives, could be just as emotional:
‘There is always the assumption that it is the big resus cases that trigger the most stress but it is unique to the individual. It could be a relative being rude to you, a complaint, a missed fracture, which is comparatively minor to the resus stuff but still as equally unsettling.’
ED11
Individual (personal) stressors
Most candidates (9/12) identified cumulative stress as just as significant as the one-off cases and all participants spontaneously referred to their own personal stressors within the ED environment. All their responses could be categorised into feelings of being overwhelmed, feeling out of control and issues with lack of resources. The emotions identified in these responses were feelings of guilt, irritation, frustration, crying, sadness, feelings of inadequacy and anxiety. Participants also reported that, when they felt stressed, they were concerned with the peer perception of not being able to cope:
‘People appear to cope better than me. When I start to struggle with the work load, I feel completely incompetent.’
ED03
The individual stressors for accessing PACE that emerged from the interviews are outlined in Figure 3.
Figure 3. Stressors for accessing PACE (percentages represent share of all mentions of stressors during the interviews)
Coping strategies
Disassociation and avoidance were coping strategies utilised by half the participants who described coping in ways such as: ‘you bury it’ (ED02), ‘pretend it has not happened’ (ED01) and ‘let it go and return tomorrow’ (ED09). One participant went into more detail about their coping mechanism:
‘Cut off and do not dwell; do something about the things you can and accept the things you cannot.’
ED06
PACE experience
The next superordinate theme was the personal experience of the PACE service. The subordinate themes were: emotions experienced; thoughts about one-to-one assessment; time frame between assessments; views about the Secondary Traumatic Stress Scale (STSS); and experience of the peer aspect of the service.
Emotions experienced
All of the participants who had undergone PACE described the programme as either useful, helpful, supportive or educational. Ten participants recognised that it was used as a signpost for further support, 11 participants described PACE itself as supportive and it was identified as educational by 6 participants as they described how it helped them recognise their own stress reactions.
‘For years I have always just put my head down and got on with it, but this one incident I just couldn't.’
ED09
Another important finding seemed to be the number of staff (5/12) who felt that the psychoeducational aspect of the PACE programme was particularly reassuring in normalising their reactions to a traumatic event or stressful situation, that ‘to be told my reactions were normal was reassuring’ (ED03, ED05, ED02, ED08, ED01).
However, one of the participants responded that they did not personally find PACE of any benefit:
‘I can see it working for others, but not for me. I have my own coping strategies and way of supporting people.’
ED06
Thoughts about the one-to-one (peer) assessment
Ten out of 12 candidates vocalised being very satisfied with the one-to-one element behind the programme, and the concept of a private discussion was highlighted by all of the participants as beneficial:
‘It's good to talk instead of pretending things have not happened.’
ED01
‘It's nice to know someone cares about my wellbeing.’
ED08
‘It felt like someone was genuinely interested in me.’
ED03
Time frame between assessments
All candidates described being satisfied with the 4-week time frame of the STSS assessment. ED03 had met the threshold specified for referral to occupational health at the 4-week stage post incident, but not at the 72-hour stage and commented that:
‘This is a good amount of time, a week or so is too soon, a month is enough time to realise that for me it was not a one-off incident making me stressed … My score was higher at 4 weeks and I had started to look for other jobs but instead, now I am getting extra support, I'll give that a go first.’
This was only one personal view regarding time frames so further research would be required for validation, but this example does concur with NICE (2018) guidelines suggesting a period of 4 weeks for stress reactions to manifest or subside.
Thoughts about the STSS
Ten participants had no concerns with questions asked in the STSS tool. The closed structure of the questions was quite significant for four of the participant:
‘They are not too invasive, which is appropriate for the nature of this … You [the PACE facilitator] are not there to psychoanalyse, you are there to support and signpost.’
ED11
‘I didn't feel attacked by the questions or that you were trying to delve too deeply, that would have made me uncomfortable. I was really struggling at the time, I could not talk about my incident conversationally without getting upset, I could keep my composure because you were asking if I am avoiding things and sleeping, not [asking if I am] sat at home crying.’
ED02
The heterogeneity of questions was openly discussed by the participants.
‘The questions were thought-provoking, they covered all angles, the question over my sleep made me realise the physical impact my incident had had on me.’
ED09
Thoughts about the peer assessment in future
Four participants voiced concern about being judged by other peers so highlighted the benefit of having a wide range of staff trained.
‘Choice is the main thing, you need to feel comfortable with the person.’
ED07
A hierarchical issue became evident in the transcripts. One candidate felt that it was important to speak to someone more senior as ‘you are escalating the problem’ (ED03), whereas another preferred to speak to someone on the same grade:
‘I would go to a consultant if a colleague was not trained, but I would not go to my supervisor, just in case it affected my appraisal.’
ED10
The remaining sample reported no issue with hierarchy and expressed that they were happy to have a PACE assessment from any grade of professional.
Confidentiality was a concern for two of the candidates.
‘I would not want the senior staff to know I was struggling, I would be embarrassed.’
ED01
Discussion
Overall, this small study has demonstrated that there is a clear need for a structured support service within the ED following traumatic exposure. Moreover, some positive aspects of the service were a reduction in stigma associated with coping mechanisms among ED staff and the potential for increased staff retention through structured follow-up. Many EDs do not have a formal structure in place, this was identified in a benchmark process against the other EDs within the north west of England before the development of PACE.
Another important finding of this study is related to educating staff in acute stress reactions—education could be given prior to an event occurring because within the ‘emotions experienced’ theme, staff found normalising their experience to be useful. Furthermore, the participants felt reassured by the psychoeducation surrounding normal stress reactions provided by the PACE service. This concurs with research by Lubin et al (2007) that found lower prevalence rates of PTSD among ED doctors in Judea and Samaria as a result of educational awareness in stress reactions.
The PACE experience was well received and described by the vast majority of candidates as supportive, helpful and educational compared to what is currently offered within the ED. This research has confirmed with previous literature that working within the ED is high pressured due to the uncontrollable and crowded work environment (Somville et al, 2016; Fitzgerald et al, 2017; Ratrout and Hamdan-Mansour, 2020). At the time PACE was introduced, support within the ED was given on an ad hoc basis and eight participants reflected this within the study findings. Some participants in this study described how they used avoidance behaviours to cope after traumatic exposure. Avoidance coping has been construed by Hagenaars et al (2010) as maladaptive and may inhibit the recovery process from the event.
Stigma and peer perception were common themes within the transcripts. Nine participants felt that there was a perception to ‘just get on with it’ and seven identified that the emotional display of crying represented a lack of professionalism. Peer concerns identified by Minnie et al (2015) concluded that despite emergency care staff experiencing many reactions following trauma, admitting to being emotionally affected was difficult due to concerns around image and capability. Research has suggested that emergency staff suppress or avoid their emotions to live up to the perception of being ‘strong’ and resilient (Wagner, 2005).
The personal element of the one-to-one discussion appeared to benefit staff; everyone who had the PACE assessment felt ‘cared for’ through the simple act of someone taking an interest in their individual wellbeing following a traumatic or stressful event. The concise nature of the STSS tool also allowed for assessment of reactions, but did not intrude mentally on the individual, and this was appreciated by the majority of participants, confirming that PACE is intended as a screening and not a diagnostic or counselling tool.
All participants appeared satisfied with the time frame and follow-up within the PACE programme. It benefited one candidate markedly because they met the threshold for referral to occupational health at the 4-week stage. This coincides with the prior criticism of the CISD model being limited by a one-off session (Regel, 2007; Gallagher and McGilloway, 2009; Burchill, 2019).
The PACE assessment was designed for post-traumatic exposure but not all traumatic work situations are viewed as negative, there are occasions where traumatic or stressful experiences have had a positive effect on individual personal growth (Slade et al, 2019). As the education component behind the service/course appeared to be of benefit, educating staff in what to expect in stress reactions prior to an event occurring may be of as much benefit as the actual PACE assessment itself.
Limitations
PACE is the first structured protocol of its type used within the ED in question. The experience of PACE was viewed through the lens of 12 ED professionals so more research will be required in the future. The main limitation to this study was that the creator of PACE is the first author of this study. Every effort was made to ensure candour was established during the interviews: first, to avoid researcher bias and, second, to identify the importance and responsibility of the honest feedback required to determine whether this support method would be of benefit or detriment to the staff who use the service in the future.
As part of ongoing service evaluation, research and data analysis need to continue, but be undertaken by a neutral candidate and not the creator of PACE.
Conclusions
This study identified that the stressors involved in the ED included one-off events such as trauma, complex paediatric cases and cumulative stress. Crowding issues, time pressures, lack of resources, increased workload, staff perception and conflict were also factors. In turn, this pressure developed into feelings of guilt, frustration and emotions described as ‘overwhelming’ by the staff. There were also concerns regarding peer pressure, image and displaying distress. The lack of previous support was highlighted as an issue by the majority of participants.
Overall, the PACE service was well received, two of the participants acknowledged its use but had their own personal coping strategies. There was a positive association with the one-to-one element, and the educational component helped to reduce the stigma associated with stress reactions after exposure. This service presently does not exist elsewhere in the NHS therefore, further research will be needed to evaluate its long-term impact and effectiveness on a wider scale.
KEY POINTS
- It is well recognised that the emergency department (ED) is a high-pressure, stressful work environment
- Increased understanding of stress reactions and psychological support may improve resilience in staff and reduce the prevalence of mental illness
- Currently in the UK there is no structured peer support service to support people following traumatic exposure—support is given on an ad-hoc basis
- The Peer Assessment after Clinical Exposure (PACE) programme aims to provide such a structured support service following traumatic exposure in the ED
- The cohort involved in this service evaluation found the PACE programme supportive and educational. ‘Normalising’ reactions to traumatic events was found to be particularly helpful
CPD reflective questions
- Do you have a structured support programme for staff within your department? What protective factors could you use to support yourself and your team during your career?
- Given the situation with the coronavirus pandemic, would an education in stress reactions and how to manage those reactions be of use to you and your colleagues?
- Would a wellbeing and stress reaction education be useful as part of the appraisal process? Do you think staff support should be identified after an event or should it be a continuing process? Should we wait for an event to happen?
- What causes you stress in your day-to-day work and how do you manage that stress level? Do you think that all traumatic/stressful experiences are negative or is there an opportunity for personal growth?