Activity Transcript

Mary-Rose Ballard, BSc, MBBS, MRCPCH: Hello, my name is Mary-Rose Ballard. I'm a pediatric registrar working in Northwest London in the UK. I'm pleased to present to you this program entitled “Strategies to Build Team Morale and Mitigate Stress in Neonatal Care Units”. In this program, we'll be discussing the following in the context of neonatal care units. Firstly, best practice strategies to build team morale and mitigate stress. And secondly, how to advocate for the implementation of these strategies. We'll start by looking at why this is such an important topic in neonatal care. Caring for sick babies and those who are born too early is unsurprisingly a clinically and very emotionally demanding role, and this can lead to a high prevalence of stress and burnout among clinical staff.

This is evident in the literature, for example, this cross-sectional study from Italy titled Post-Traumatic Stress and Burnout in Neonatal Care Staff or The STRONG Study. This web survey comprised of a range of neonatal unit workers, 227 in total, and found that over a third had symptoms of medium and severe post-traumatic stress, which was even higher if workers experienced frequent, which they classified as 4 or more per month, losses of babies in the unit. They found that those with training in bereavement care or communication were actually less likely to develop stress symptoms. Another survey from the UK looking again at a range of neonatal workers, but predominantly nursing staff, had 719 respondents. They found that working in the neonatal environment negatively impacted mental health and wellbeing for those staff, and 70% of the respondents reported that they felt frequently ill or run down. Their symptoms appeared to depend on many factors, for example, understaffing and an unmanageable workload, and also dealing with traumatic events in their day job.

There's a risk of a vicious cycle here, with over half of these workers taking time off in the last year due to their mental health and 48% of those considering leaving, which could potentially worsen those problems with understaffing and an unmanageable workload. Clearly then, preventing, recognizing, and managing burnout is extremely important to protecting neonatal staff's wellbeing and the impact on services. This conceptual model shows a coping reserve or tank for each individual based on their own personality and temperament and shows how negative inputs such as stress and demands can be counteracted by positive inputs, such as psychological support, mentorship, and intellectual stimulation. These together can impact the outcomes, which are burnout and staff members' resilience.

We really mustn't forget the importance of the environment around an individual as well, such as having a no-blame or name-and-shame culture. There are many factors then that we can try to influence to protect neonatal staff, such as supporting them, mentoring staff, and promoting professional development. To summarize so far, the impact of stress on staff wellbeing can be significant. Reducing stress can be used to improve team morale, improve wellbeing of staff, and therefore can also improve staffing through reduced staff absences and those high levels of turnover. Overall, this has potential to improve the quality of care that we provide to babies and their families, and therefore also has the potential to improve infants' outcomes in the longer term.

So now we will talk about potential strategies to mitigate stress and to build team morale. I'll start with an example case, just to illustrate some of the challenges that we face in neonatal care and managing stress. In this example, we have a term infant born at 41 plus 1 week gestation who required an emergency cesarean section because of fetal bradycardia. The baby was born in poor condition and required full resuscitation with CPR, intubation, administration of drugs, and had an acceptable heart rate detected for the first time at 12 minutes of life. The environment in this case was, as is not unheard of, extremely tense, and there were actually multiple teams in theater because the mother also suffered a major hemorrhage and the father then also collapsed in the theater as well. So, there were many different members of staff that were involved in the care of the family.

In this example, we were able to organize what was called a hot debrief occurring shortly after the event and after the baby had their initial stabilization on the neonatal unit. There were many barriers to holding this debrief. For example, having a sick baby and a sick mother, high acuity elsewhere on the neonatal unit and a very busy labor ward, and having multiple different staff that needed to be brought together. However, taking a short interlude during this care to have a debrief for the team can be extremely helpful long-term and very much worth the investment. So why is this important?

Debriefs after significant clinical events such as this one can help to not only identify learning points, which can promote professional development, but also to help acknowledge individuals' emotional states after a significant event. It can help the team to feel supported and can help individuals to process the emotional impact of what's happened. It's really important that these debriefs do not aim to place blame, but aim to promote learning. There are different types of debrief. These can be informal, which is the classic coffee room chat after a long day or a night shift. But then there are also things called a hot debrief, which is like that we've described in the scenario, which occur right after the event. And a cold debrief, which usually occurs sometime after the event. And we'll go on to talk about both of these.

So, what are the key principles of debriefing? The first principle is that there should be a facilitator who leads the debrief. Ideally, this person would be trained, but practically that isn't always possible. The person doesn't need to have been part of the incident. But again, in acute clinical scenarios, and particularly for a hot debrief, this is usually the case. Often this will be a lead clinician. But as with most resuscitation scenarios, sometimes the lead may not be a clinician but maybe someone else who's more appropriate, such as an experienced nurse who feels confident to do so. The second principle is of psychological safety. This is paramount. Team members must feel that they are able to speak freely, admit to mistakes, and raise concerns about patient safety without having any blame or judgment.

They need to know that the aim is learning and improving safety, but not blaming staff. The third principle is that support and resources for staff should be made clear. In my department, for example, where I work, there are a range of resources for staff to access themselves, as well as peer support and counseling. These should be made clear at the end of the debrief and it shouldn't be assumed that all staff members are aware, as they may well not be. We'll talk now about a hot debrief like we did in the case scenario.

Who should be at a hot debrief? Everybody should be invited. Everybody is part of the team. You should include anybody that was involved. And that's not just the doctors, nurses, and midwives, there may be a medical or nursing student who was scribing. Or even a porter, for example, that had brought some emergency treatments. These may both be affected, and all people may have useful insights to learn from. When? Usually this would be as soon as possible after the patient is clinically safe. The event is still fresh in everybody's minds and it's much harder to catch people after they've left from a clinical scenario. And particularly with different rotor patterns, it may be difficult to bring them together again. Where? Often a quiet practical place is the best place. This would usually be in the same clinical area or nearby so that people do not have to travel far and are able to feel that they can attend.

How should we do this? Well, we should remove distractions wherever possible and encourage as much participation as you can. You shouldn't put people on the spot, but individuals should have an open space to speak. And that psychological safety that we discussed is paramount and must be made very clear. Initially, the whole group should be encouraged to talk through what happened and not one individual put on the spot. And then people should be encouraged to discuss how they're feeling now and what their learning points were from the event. Following this, the learning points should be discussed, considering what went well and then what can be changed to improve patient safety for future cases. And then at the end, an action plan should be discussed and a cold debrief should be scheduled or at least a tentative date suggested.

The cold debrief. A cold debrief is very similar to a hot debrief. The principles are the same, but there are some differences. Typically, a cold debrief would happen later than the event, often in the next few days or week. It's very important to ensure everybody has plenty of notice because shifts do not always align. And a very clear date, time and location should be set for this to allow people to attend. In my practice, it's usually run outside of the clinical environment and typically we would have a psychologist present, as they can be extremely helpful. And usually there is then time to arrange this. Overall, the structure is very similar. The scene should be set often in somewhat more detail, as some time may have passed and people may have forgotten the key points of the case. And psychological safety again should be made very clear.

Following that, an explanation of what had happened and people's feelings afterwards should be explored. There should be a summary of the main learning points and future practice, and then there should be some signposting to support networks for individuals who may be needing some extra support. There are some other tools that we can use to help support professional and personal development and help to boost resilience, and these include self-reflection. Reflecting on what happened at a personal level can help individuals identify not only their own strengths and learning needs, which can also then go on to help improve patient care. This is an important component of pediatric training. For example, in the UK we're required to write reflections on our online portfolios, and specifically for any series incidents that we may have been involved in.

There are plenty of models to help guide writing reflections. One of these, the Gibbs' Reflective Cycle, which is demonstrated here is used commonly. Gibbs focuses on initially describing what happened, describing the feelings at that time, and then evaluating those. It then facilitates and guides analysis so that conclusions about what happened, and an action plan can be made for future learning. Reflections may bring up learning needs that an individual feels they need support with, and they should be encouraged to discuss this with their supervisor so that appropriate steps can be taken for their learning and for patient safety. It is important to support individuals during follow-up investigations. Some clinical scenarios will trigger a need for further investigation, particularly if there is a neonatal death, for example. The aim of these is not typically to assign blame, but to find learning points and to improve patient safety processes. These can nevertheless be extremely stressful for staff that are involved, and supervisors and other appropriate staff, such as patient safety leads, should provide guidance and support to those individuals through that process.

Finally, whilst not the main focus of this program, another way to improve longer-term team communication and to boost team morale is simulation training. Neonatal resuscitation is fortunately not a common occurrence, making simulation very helpful. It can increase staff familiarity with protocols, increase their familiarity with the environment around them and with each other. Multidisciplinary simulation in particular can help with team building. It helps people learn each other's names, their roles, and also their skills, which may not be apparent in an emergency. This can also help to improve human factors in real-life emergencies, as well as team building. Many neonatal units that I've worked at have regular simulation training, often multidisciplinary, as part of their teaching program, and it really does help to build that team morale.

So, in conclusion, neonatal care staff do frequently experience high levels of secondary traumatic stress and burnout, which can impact the culture at work and result in low team morale and high staff turnover. In order to help improve the quality of care and protect staff mental health and wellbeing, it's absolutely essential that stress mitigation strategies are implemented. These strategies, like we've discussed, include hot and cold debriefing, often with a psychologist, if possible, include reflection practices and also simulation. Thank you so much for participating in this activity. Please go on to complete the questions following this. Thank you.

This transcript has not been copyedited.