Staff support for workplace trauma: a freedom of information act request survey for NHS trusts providing mental health care in England

Abstract

Introduction

Workplace trauma in mental health settings is defined as exposure to verbal and physical aggression, witnessing self-harm or hearing about patients’ histories of abuse. Support for workplace trauma is important for staff well-being, staff retention and ultimately patient care. Assessing the extent and adequacy of staff support for workplace trauma in mental health settings is important in identifying areas of need and good practice.

Aim

To determine what staff support systems are in place for workplace trauma in mental health services across England.

Methods

Freedom of Information Act requests were sent to all 57 National Health Service Trusts providing mental health care in England to identify policies on the support to mental health staff after traumatic incidents that they have experienced in the course of their clinical duties.

Results

Fifty-five Trusts provided usable data. Only half provided evidence of a psychologically informed incident response that went beyond a fact-finding exercise and only a fifth of Trusts used an established model for the response process. A small proportion of policies acknowledged workplace traumas related to staff discrimination on the basis of protected characteristics.

Conclusion

There is insufficient attention to supporting mental health staff with the effects of workplace trauma.

Key words:

• trauma
• staff
• discrimination
• support

Introduction

Mental health staff often experience traumatising events at work known as ‘workplace trauma’. For example, data from national databases suggest that National Health Service (NHS) workers in the UK were subject to 68,683 physical assaults between 2013 and 2014 and 70% of these occurred within the mental health sector (Renwick et al., 2016). Mental health inpatient staff also report distress and fear when physically restraining patients to manage risk and frequently witness self-harm, such as cutting, head banging or self-ligation and suffocation (Akinola & Rayner, 2022; Muir-Cochrane et al., 2018). Furthermore, they often experience verbal abuse (e.g. verbal insults, threats of violence, and sexual harassment) (Stewart & Bowers, 2013) and hear graphic accounts of violent crimes, suicide attempts or childhood abuse (Christodoulou-Fella et al., 2017). Staff from minority groups who make up a significant proportion of the NHS workforce (estimated 40%), also experience racism, homophobia and abuse related to disabilities from both patients and/or co-workers on top of ‘general’ workplace trauma (Alexander, 2021, NHS England 2022; 2023; Stewart & Bowers, 2013).

Workplace trauma may lead to staff mental ill health (e.g. anxiety, depression and PTSD) and high staff absenteeism and turnover (Jacobowitz 2013; Needham et al., 2005; Sofield & Salmond, 2003). These in turn may result in poor patient care and consequent rises inpatient aggression, self-harm and suicide (Weltens et al., 2021). External scrutiny resulting from concerns about care could further increase the pressure staff face (Currid, 2008). There are also large NHS costs associated with poor care, serious incidents, and staff sickness and turnover (Copeland, 2019; Farrah, 2022).

Healthcare organisations have a duty to protect staff from physical and psychological harm and employers increasingly see the benefits of well-being interventions to support staff (Heath & Safety Executive, 1999; Wagner et al., 2016). Inquiries into negligent patient care often pinpoint poor staff well-being and inadequate supportsupport for staff (e.g. Francis Report Public Inquiry, 2013). Reports following inquiries into negligent health care outline standards for improving well-being at work which focus on opening up dialogues about mental health and raising awareness of available support (Mind, 2021). A recent review paper of 23 studies on organisational factors and trauma symptoms in mental health staff concluded that the risk of trauma symptoms was lowered when staff had regular supervision with supportive supervisors, strong peer support networks and balanced and diverse caseloads (Sutton et al., 2022). Work cultures that acknowledged the existence of trauma symptoms in staff were also important (NICE, 2015). Similarly, NICE guidance recommends employers make proactive changes that prevent the development of mental ill health rather than only focusing on the treatment of ‘symptoms’ (NICE, 2015; 2022). Evidence-based prevention and treatment strategies are also needed that are tailored to the specific challenges of each workplace and the needs of different individuals (British Psychological Society 2022). However, there are well-known inconsistencies and gaps across NHS in terms of staff support systems ([BPS], 2022). To our knowledge, some Trusts have staff support systems, but often these do not focus on the prevention of development of poor mental health nor address barriers to access (e.g. stigma of help-seeking in staff or the needs of specific groups of staff) (British Psychological Society, 2022). We also believe that most current systems have developed without reference to the process of theory building and iterative testing advocated by the Medical Research Council frameworks (Skivington et al., 2021).

In order, to more objectively quantify and describe staff support systems for workplace trauma this study aimed to identify trust policies that relate to support provided to mental health staff after traumatic incidents in the workplace place. A further aim was to assess the adequacy of the policies in terms of: a) models of trauma support; b) focus on prevention; c) specific reference to the needs of staff from minority groups.

Method

Our aims were addressed using a cross-sectional design focused on all 57 NHS Trusts in England providing mental health care at the time of commencing the survey. In December 2022, a Freedom of Information Act (FOI) request was sent to the FOI Officer of each NHS Trusts. The Act entitles anyone to request information from any public sector body and does not require ethical approval or participant consent processes. Our request was as follows:

Please could you send me all trust policies related to support that is provided to mental health staff after traumatic incidents that they have experienced in the course of their clinical duties. For example, after they have been physically or sexually assaulted or harassed, or witnessed sudden and unexpected death or serious injury, or witnessed self-harm or suicide attempts, or been involved in a fire.

To assess the information provided and each policy, we designed a data extraction tool based on NICE guidance for supporting employee emotional well-being and models of trauma support such as Critical Incident Stress Management (CISM), Psychological First Aid (PFA) and Trauma Risk Management (TRiM) (Everly et al., 2000; NICE., 2022; Public Health England, 2021; Whybrow et al., 2015). For example, information extracted included: whether or not the Trust had a post-incident response process with a supportive component that went beyond fact findings; whether staff engagement in this process was optional; whether the Trust had policies aimed at proactively protecting against the adverse effects of staff trauma (as opposed to being solely reactive following incidents); whether policies were informed by established models; and whether policies contained specific information about incidents involving discrimination based on protected characteristics. We also extracted more specific information to describe policies that we deemed comprehensive but not labelled in terms of a model already described in the literature. The information extracted included: whether there was a dedicated team or resource to provide the support, whether staff were providing the support were given training in the approach and whether the model had a stepped model and/or stages of support.

Three of the researchers were involved in the rating process and information from each Trust was doubly extracted. Any discrepancies were discussed and resolved within the group of raters. The majority of disagreements related to whether staff involvement in the response process was optional as in some cases this was implied (e.g. managers could ask staff to attend a debrief) rather than explicit. Similarly, there were some discrepancies in whether policies made specific reference to protected characteristics. For example, in a few cases discrimination based on racism was listed as a type of incident but there was no specific information about special considerations for preventing adverse effects from these types of incidents.

We carried out data analysis data between March and May 2023 and accepted information from Trusts up until the end of the analysis period. No new data was received after May 2023.

Results

Fifty-five of the 57 NHS Trusts (97%) provided some usable data. Two Trusts did not provide any response. Table 1 provides summary data for the information extracted from the policies. Fifty-seven percent of the Trusts who responded to us had a psychologically informed incident response process following workplace traumatic incidents that went beyond fact-finding. A total of 45% of these incident response processes were clearly indicated as optional, and the rest were not explicit about whether or not staff attendance was a requirement.

Only 18% of Trusts described an established approach (either citing TRIM or Critical Incident Stress Debrief, CISD). A further 14 Trusts described other comprehensive and systematic approach to their responses to incidents which involved training and/or supervising a dedicated team of staff in the approach and a stepped model of support which involved offering more individualised support for those who requested it or were identified as still struggling beyond initial supportive staff sessions. These approaches primarily adopted a phased approached to responding to trauma which included an initial staff meeting focused on psychoeducation and support typically followed by additional meetings or checks on staff wellbeing over time with options for more focused support for staff who continued to experience psychological distress. More focused support was provided by Occupational Health, staff counselling services or Improving Access to Psychological Therapies services.

However, only two Trusts described an approach to proactively protect against the impact of workplace trauma, which included offering more focused reflective practice in areas of high acuity and training and supervising selected staff in recognising and responding to signs of trauma symptoms in colleagues. It was noteworthy that 22 Trusts reported staff wellbeing policies which generally related to identifying triggers, signs of and sources of support for staff but these policies did not specifically refer to workplace traumas and were separate from incident response policies.

Discussion

Just over half of the Trusts who responded had a serious incident response process that went beyond a fact-finding exercise. However, in most cases, there was no evidence that this process was informed by a psychological model previously described in the literature. It was also often unclear if staff involvement was compulsory or optional. The main models that were described were CISD and TriM or similar phased approaches which were not explicitly labelled in relation to an established approach.

Even though CISD and TriM are established approaches to trauma management, it is important to note that they are not evidence-based. Overall, the evidence base for CISD is more developed and indicates either no impact or a harmful impact on relevant PTSD outcomes. Meta analyses indicate that single-session individual psychological debriefing interventions including CISD and CISD specifically neither prevent the onset of PTSD, nor reduce PTSD symptom severity or general psychological morbidity (Rose et al., 2002; Van Emmerik et al., 2002). On the contrary, there is limited but high-quality evidence that these interventions increase the risk of PTSD at long-term (13 months) follow-up, potentially because the interventions expose participants to greater re-experiencing of the traumatic event/s in the aftermath (Bisson et al., 1997; Rose et al., 2022). In a later RCT, an adapted, multi-session, model of CISD demonstrated no benefit compared with the control arm in preventing PTSD or reducing symptom severity (Marchand et al., 2006).

The evidence base for TRiM is less developed, provides very limited evidence of effectiveness in any context and no evidence in a non-military healthcare context. For example, TriM has been subjected to non-experimental evaluation in police officers and quasi-experimental evaluations in military contexts (Frappell-Cooke et al., 2010; Gould et al., 2007; Hunt et al., 2013; Watson & Andrews, 2018). The only RCT, to our knowledge, was conducted in a naval context and found no significant benefit of TRiM compared with the control arm in psychological health outcomes (Greenberg et al., 2010).

Previous reviews highlight the importance of a preventative approach to managing the effects of workplace trauma (Sutton et al., 2022). Preventative approaches ensure that organisations foster a culture in which individuals feel safe to speak about the presence and effects of workplace trauma with peers, supervisors and teams. For example, staff training should highlight and normalise the psychological impacts of the work, supervisors should proactively ask about exposure to or fears about exposure to workplace trauma and forums should be created so that staff teams can regularly reflect on their working environment and learn to share experiences in a supportive milieu. Promoting open and supportive discussion of workplace trauma and its effects is likely to minimise the impact of workplace traumas on staff by ensuring that they recognise their emotional responses to events and seek support both within and outside of the organisation.

However, the majority of Trusts did not have a preventative approach to mitigate against the effects of workplace trauma. It is noteworthy that some Trusts did send us policies related to staff wellbeing at work which were separate to policies on staff support in relation to serious incidents. Arguably, some elements of these policies may be relevant to preventative approaches to mitigate against the negative effects of workplace trauma. Nonetheless, these policies did not specifically mention workplace traumas and were primarily related to team managers assessing and responding to triggers and signs of stress within the workforce. We therefore felt that they did not meet the criterion of prevention by promoting a work culture that acknowledges and promotes conversation about the presence of trauma and its effects in the workplace. Nor was there evidence of how the system of managers identifying stress within the workforce would seamlessly tie in with support from specifically trained staff in serious incidents.

The majority of Trusts also did not mention the incidents of workplace trauma and specific effects of workplace trauma related to discrimination, nor how staff from minority groups may experience additional barriers in seeking support. This is concerning as data from across the NHS suggests that a higher proportion of ethnic minority staff compared to White British staff experience harassment, bullying or abuse from patients, relatives or the public (British Medical Association, 2021; NHS England, 2023; Royal College of Psychiatrists, 2021). The 2020 NHS staff survey found that over 20% of gay or lesbian staff reported discrimination from patients and colleagues which is higher than other NHS staff (and is likely to be higher if we consider unreported data) (Alexander, 2021). These figures are similar for disabled staff and are also likely to be higher in mental health settings where abuse of staff is more prevalent (NHS SCW, 2021; Stewart & Bowers, 2013). The effects of workplace trauma may be particularly marked for staff from minority groups. For example, very recent research shows that NHS staff from ethnic or sexual minority groups and/or those who have a disability have a lower health status and/or greater mental health difficulties than other NHS staff (Varese, 2021).

Even when Trusts did have staff support systems in place, this did not mitigate against barriers to access. Stigma around mental health and help-seeking still exists within healthcare services (Kanno & Giddings, 2017). Fear of being judged or discriminated against is especially marked among mental health staff. There is a myth that supporting mental health patients means your mental health must be under control (Kanno & Giddings, 2017). NHS staff from minority groups are also underrepresented amongst those who seek support, suggesting issues with underreporting and accessibility of current support systems (Varese, 2021).

Strengths and limitations

Our survey had an excellent response rate yet the failure of some Trusts to identify relevant policies could be a limitation as we may not have had access to all relevant information. However, these latter responses, constitute important findings in their own right, about whether Trusts have readily identifiable policies in relation to workplace trauma (albeit poorly developed). Some of the data may also be out of date by the time of publication as it is noteworthy that three of the Trust suggested that policies were being updated. The study generated no data from service providers other than NHS Trusts. It seems particularly problematic that some mental health act providers are operating beyond the jurisdiction of the FOI Act. This represents an uneven playing field for NHS providers and private organizations in relation to costs and accountability.

Conclusions and recommendations

The majority of Trusts in England are not employing a preventative approach to addressing the effects of workplace trauma and the reactive models that are in place are not evidence-based based nor do they address likely barriers to access.

It is important to articulate an approach which mental health organisations should adopt in relation to workplace trauma. This approach should incorporate both a psychologically-informed response to serious incidents as well as a culture which promotes conversations about workplace trauma and effects through training, supervision and team reflective practice. Information provided by some organisations in this survey would be in keeping in this approach and could be used to develop national guidance. However, even within the more psychologically-informed and preventative approaches, it is clear that more research is needed to understand and address barriers to access for minority groups who may be more exposed to the effects of workplace trauma This work should be carried out in partnership with individuals from minority groups who are best placed to understand the barriers concerned and how to access the views of people who may understandably mistrusting of research conducted by majority groups. As a follow on from this study, expert consensus methods could be used to derive key components of best practice from the information we obtained in this survey. For the aforementioned reasons, it is important to include experts from minority groups within these consensus methods.

Involving experts in generating key components of best practice would help to ensure that we capture policies and approaches not identified by our survey and that key influencers within NHS organisations are aware of the work. However, in terms of bringing about longer-term change in the health services by creating evidence-based practice, it is equally important to develop this guidance alongside research which evaluates the effects of the guidance in terms of uptake and on staff wellbeing, staff retention, patient experiences of care and cost savings.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Table 1. Summary data.

Evidence of a psychologically-informed response process	Evidence of measures to proactively protect against the adverse effects of staff trauma	Reference to established model related to trauma response	Inclusion of specific info about discrimination based on protected characteristics
31/55	2/55	10/55 5 TRIM 5 CISD	15/55

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.