Trainee Wellbeing Initiative Award 2022 top 3 applications

Winner - Bath Team Immediate Meet (TIM) tool team

Project lead – Dr Fiona Kelly

Project team – Layla Guscoth, Rachel Beer, Matthew Aldridge, Matthew Edmondson, Toby Johnson, Julie Highfield, Kat Herneman, Fran Millinchamp, Sarah Gouldson, Fiona Kelly

Royal United Hospitals Bath, Intensive Care Society

Project aims:

It is inevitable that anaesthetists and the teams in which they work will have to deal with difficult situations and potentially traumatic events during their working lives. Trauma Risk Management (TRiM), a peer support tool designed to help staff prepare for and recover from potentially traumatic events, was introduced in our hospital in 2012. During the COVID-19 pandemic first wave, we recognised that TRiM was not being used to its maximal potential, identifying the following issues: many frontline clinical staff were anxious about leading short ‘hot debriefs’, especially when upset themselves or when suffering from cognitive overload after an emergency; lists of staff involved were not always compiled immediately after a difficult event, with it challenging to do this at a later stage; many staff were unsure how to make a TRiM referral or access TRiM services; those TRiM referrals that were made were often incomplete and/or sent late; and not all staff were familiar with what was normal to expect after a difficult event.  

Our team therefore designed and developed a Team Immediate Meet (TIM) tool: page one is a communication aid, designed to be read out immediately after a critical event as a two-minute ‘hot debrief’ tool; page two (on the back) is a self-care guide, describing normal feelings and recommended actions for staff involved in a difficult event, designed to be read by staff when they take a break in the coffee room. The TIM tool is displayed in each operating theatre, in central locations in the Intensive Care Unit (ICU), in coffee rooms and changing rooms. 

Our aims were to provide practical guidance for anaesthetists and their teams in leading a short ‘hot debrief’, normalise the reaction after a potentially traumatic event, prompt the immediate writing of a list of staff involved and provide self-care advice.

TIM tool ‘tea trolley’ training feedback:

TIM tool trolley training has been provided for 160 multidisciplinary staff to date including: doctors of all grades; anaesthetics assistants; theatre, PACU and ICU nurses; HCAs; physiotherapists and other allied health professionals. Feedback forms were completed by 77% of participants, results as follows: 29% reported that they were confident using the TIM tool before training and 89% after training; 94% reported that this tool would help themselves and their colleagues navigate the aftermath of a potentially traumatic event. Free text comments: 

• “I love the structure of this. Even if my head were in a spin and/or I was too upset to think I’m sure I could read this out”
• “We like the fact that two of us could read this out together especially when we are doing night shifts with new junior doctors”
• “Reading this really helps me realise that difficult shifts are to be expected and if I find them hard then that just shows that I’m caring – not weak or incompetent”
• “I think this is brilliant as I often get home after a night shift, and think that I should have run a debrief after a difficult case but that we didn’t manage to fit it in. I really worry about my team - this is something practical that will help my wellbeing as well as that of the team”

Bath TRiM data

Following an updated TIM tool re-launch (September 2021), our TRiM team have observed the following: increase in TRiM referrals made per month; wider range of staff making TRiM referrals (rather than reliance on the departmental wellbeing team); TRiM referrals made more quickly after an event, allowing staff quicker access to support if needed; TRiM referrals more complete and more likely to contain full names and email addresses.

Beneficial effects on wellbeing

The TIM tool benefits anaesthetists and their colleagues in the following ways:

1. Facilitating a short ‘hot debrief’ 

There is often reliance on the senior anaesthetist to lead a short team ‘hot debrief’, but they may not feel able to do so due to lack of training/experience, feeling shook up themselves or being called away to speak to relatives. The TIM tool first page is designed to be read out by any member of the multidisciplinary team, aiming to make the ‘hot debrief’ process easier in a difficult situation, empowering all team members to lead a debrief and to prompt the following actions: staff to pause for two minutes, thank the team, explain factually what happened in 1-2 sentences, explain that it is normal to feel shook up, encourage everyone to take a break when possible and prompt collation of a list of everyone involved immediately   

2. Facilitating staff follow-up   

Anaesthetists may be reluctant to seek help following a difficult event due to a lack of knowledge of how to do so, reluctance to speak to a counsellor/clinical psychologist or denial that they may be affected. By prompting collation of a staff list straightaway, the TIM tool facilitates a rapid referral to the TRiM team or other peer support framework/clinical psychologist, thus removing one perceived barrier. In addition, the TIM tool includes the TRiM/clinical psychologist email address to help staff access support.

3. Normalising feelings 

The TIM tool second page outlines normal feelings that may be experienced after a critical event and suggested actions based on NICE guidance and PIES principles, to help anaesthetists to help themselves and/or advise colleagues.

4. Encouraging the team to look out for each other

By vocalising that it is ‘OK not to be OK’, the TIM tool encourages anaesthetists and their teams to ‘check in’ with their colleagues

2nd place - Psychologically aware conversation training (PACT)

Project lead – Laura Oakley, Linden Baxter, Kate Grange, Carl Morris

Project team – Sarah Hudson, Laura Oakley, One of four project leads, Linden Baxter, One of four project leads, Kate Grange, One of four project leads, Carl Morris, Project supervisor, Haido Vlachos, Supervisor

Oxford University Hospitals NHS Foundation Trust, 2Buckinghamshire Healthcare NHS Trust, Health Education England Thames

Project aims:

The Psychologically Aware Conversation Training (PACT) project was developed in response to the psychological impact of the COVID-19 pandemic on junior doctors. Our aim was to make training in the conduct of ‘psychologically savvy conversations’ available to all clinicians including anaesthetists acting in supervisory or mentoring roles in our deanery.

As anaesthetic registrars with roles within wellbeing and educational governance teams, we observed the effect of the increased workload and emotional burden on our colleagues during the COVID-19 pandemic. The Royal College of Anaesthetists reported that over a third of survey respondents experienced poor or very poor mental health due to COVID-19 related pressures, with nearly 20% considering leaving the profession.

We engaged Professor Neil Greenberg’s group: March on Stress®, a psychological health consultancy who had developed a strategic approach to teaching active listening skills to healthcare staff. REACTMH teaches how to Recognise a colleague in psychological distress, Engage in a guided conversation, Actively listen, Check risk, and Talk through a plan for specific action including highlighting available support options. This proactive approach has been shown to increase organisational resilience, reducing long term mental health absence by up to 90%, therefore benefitting both individuals and organisations in retaining a healthy workforce.  

We successfully presented a business plan to Health Education England Thames Valley (HEE-TV) based on the principle of cascading training throughout the region using a Train-the-Trainer (TTT) model. This was rolled out in the spring of 2021 which allowed motivated, self-selected consultants and senior registrars in mentoring roles from every acute trust in the region to acquire the knowledge and skills to subsequently deliver the REACTMH 90-minute course locally. Our objectives were improving confidence in holding such conversations, embedding these practices within our organisations, thereby enhancing staff wellbeing and reducing absence and harm due to mental ill health.

The PACT project has enabled 53 consultants and senior trainees across the deanery to complete the train the trainer session, enabling them to deliver REACTMH 90-minute training more widely. To date, 124 people have undergone REACTMH training and of these 92 have been within anaesthetics and critical care.

As part of the feedback collected before and after training sessions we have been able demonstrate the intended improvement in participants’ confidence in supporting colleagues to find ways of improving their mental health or wellbeing. Prior to training 55% respondents stated that they were "not confident" in this regard with only 18% stating that they felt "fairly confident". Following training 100% of respondents felt at least "somewhat confident" with 59% feeling "fairly confident". In addition to this 76% respondents stated that they found the REACTMH training "extremely useful" or "very useful" in supporting a colleague who might be having difficulty with mental health or wellbeing. All respondents agreed that it had some degree of utility in this regard.

It is notoriously fraught with difficulty to attempt to attribute a particular outcome measure (such as rates of absence, time out of programme or mental ill health in a population such as anaesthetists within a deanery) to a single intervention within such a complex system. We do however plan to continue to monitor the levels of comfort and confidence that anaesthetic supervisors have in conducting wellbeing conversations with those they supervise, with ongoing signposting to the resources available to access training and practice in these skills.  A normalisation of discussions around mental health and wellbeing, and increasing familiarity with navigating these confidently are medium-term outcomes we hope to see as every supervisor is offered this training.

Beneficial effects on wellbeing

Challenges to mental health and wellbeing are widespread among anaesthetists rather than being rare occurrences. A pro-active rather than reactive approach from healthcare organisations to monitoring and addressing wellbeing issues is therefore indicated. Indeed, “wellbeing check-ins” have been mandated as part of trainee supervisory meetings addressing “Training Recovery” following COVID-19. Despite this, a majority of those managing healthcare workers in the UK, report not feeling confident in supporting a distressed colleague. REACTMH is an evidence-based training package associated with significant improvements in healthcare manager’s confidence in recognising, speaking with and supporting healthcare workers. The provision of such training has the potential to benefit organisations legally (as part of duty of care to employees), economically (by supporting people to stay at work) and morally (by looking after our people).

Other high-stress high-stakes professions such as the emergency services and the military increasingly provide training as standard in detecting and managing distress in their colleagues. Evidence from the Fire services showed that managers who had received training in identifying the need for mental health and wellbeing conversations and who successfully engaged in these conversations with their teams were associated with a reduction in long-term mental ill health by up to 90%.

Wellbeing conversation training is therefore a clear and increasingly important training gap for anaesthetists who engage in supervision, mentoring, and peer support. Cascading training through local trainers allows all anaesthetists the chance to develop their own supervisory skills and benefits all members of the team with which they work including other multidisciplinary team members similarly trained through the program. Outcome measures show clear increase in the confidence and willingness of participants to engage in wellbeing conversations following the training. We created locally tailored resource guides to outline available avenues of support, allowing creation of tangible action plans by supervisors.

3rd place - Drop Out, Survive, or Thrive? - How best can we support anaesthetic trainees following a critical incident?

Project lead - Amelia Robinson

Project team - Amelia Robinson, Project lead

Royal Berkshire Hospital

Project aims

This project about the impact of critical incidents on trainee wellbeing. Critical incidents are defined by the GMC as: "Any unintended or unexpected event, which could or did lead to harm of one or more patients. This includes incidents which did not cause harm but could have done, or where the event should have been prevented".

The literature shows a predictable post-event trajectory for staff: dropping out, surviving or thriving. This project aims to acknowledge and determine the impact on wellbeing critical incidents cause during training, to find out how best to improve the support offered to anaesthetic trainees, and then take the first steps to improve this on a trust and deanery level.

Summary of aims:

• To investigate the impact of critical incidents on anaesthetic trainees in the deanery and to explore what support services are currently accessed. This information was gathered using an initial questionnaire.
• To understand what modifies the personal and professional impact on trainees of an incident and its investigation process, as well as the barriers to accessing support for trainees, using subsequent semi-structured interviews of volunteers following the survey.
• To develop a pathway to ensure all trainees are offered support following a critical incident, and that there is a back-up process if this offer is not made promptly. This will be initially within one trust, and then can be expanded further once it has been trialed successfully.
• To improve teaching on critical incident investigation processes, what is expected of trainees and the support available following an event by development of a regional teaching day and accessible internet resources on the deanery training site and PSWS site.

The project involved an initial voluntary confidential survey of anaesthetic trainees in the region.

There were 34 responses to the survey, 14 of whom had experience of an incident leading to life altering injury or death of a patient. The impact on trainees was significant, with 7 trainees considering taking time out or changing career.

Support was varied, 8 trainees had no immediate support. The majority sought help from family and friends use of external services such as Practitioner Health was limited.

Half of respondents were asked to write a statement, only 3 had received training on this. The majority felt that training on incident investigation for trainees and supervisors would be helpful.

The subsequent semistructured interviews explored individual trainee experiences, quality of support received and suggestions for improvement.

Common themes were:

• Protective aspects such as a culture of approachability within a department and supportive discussion with a senior colleague soon after the event. 
• Damaging factors included communication breakdown within the team, and a feeling of isolation either due to negative/exclusionary departmental dynamics or feeling an outsider due to being part of a BAME group or new/unfamiliar within the trust. 
• Poor quality of communication about requirement for formal written statements or attendance at Coroner’s court, which frequently came completely unexpectedly at a time when the trainee had left the department or trust in question.
• The sensitive nature of critical incidents is challenging when trying to understand the full impact on wellbeing. However, the results of the survey and interviews show there is room for improvement in the support and training offered. Following on from the development of the written resources and regional training day, a survey for further feedback will measure the improvement made.

Beneficial effects on wellbeing

Trainees have particular barriers to accessing support following a critical incident. They are transient members of the workforce, frequently rotating to different trusts without a permanent contract. As a result they may not be familiar with local support structures, and may be excluded from certain communication due to frequent relocation. Additionally, their competency is continually assessed with time pressure to achieve training milestones in a stepwise manner. They may feel involvement in a critical incident, or highlighting this by accessing support following one, will impede their progression.

Anaesthetic trainees are a particular cohort for whom critical incidents can entail significant stress. The procedural nature of anaesthesia coupled with often working as an independent practitioner with local or distant senior supervision can feel isolating if a critical incident occurs. As a result, high quality processes for support following critical incidents are needed for anaesthetic trainees in order to combat the feeling of isolation and potential individual blame.

Review of the literature shows the impact following a critical incident is significant for anaesthetists.  In the 2005 Association of Anaesthetists members survey, 80% had experienced a intraoperative catastrophe and 10% felt that it then compromised their ability to provide anaesthesia. Despite evidence of a significant impact on patient safety, training on critical incident investigation is limited, and has been referred to as a blind spot in anaesthetic training compared to other hospital specialities (Jithoo, 2017).

By increasing the visibility of the impact of critical incidents and their investigation on trainee wellbeing, a dialogue will be opened on how best to support individuals and optimal training to offer. Evidence of the personal impact of incidents on trainees in the region will provide evidence for improvement of support services, and training on practical aspects such as written reflection, statement writing and attendance at Coroner’s court.