Finding the pressure point
Written by: Abigail James | Published: 20 September 2016
Enhanced duties, the challenges of treating an ageing population both contribute to huge levels of stress in primary care
Nurses returning from their summer holidays can recite the pre-flight safety demo word for word. You already know you need to secure your own oxygen mask before helping others. What use are you to others when you're struggling yourself?
But this idea seems lost in routine healthcare practice, where professionals compromised by workplace stress are still expected to provide high-quality care to their patients.
Mental health charity Mind published the disconcerting findings of a survey of over 1000 primary care NHS workers including GPs, practice nurses, practice managers and their colleagues. Almost 90% of respondents found their work life stressful – considerably more than the wider UK workforce (56%). Work topped the list of the most stressful aspects of the respondents' lives, trumping finances, health, family life and relationships. Coping with the stress is unsustainable for almost half (43%), who have resigned or considered resigning from their jobs due to the pressure.
This is hardly news though. General practice alone saw a 24% increase in the number of consultations between 1998 and 2012 – a trend that looks set to continue as the population ages and clinical presentations become more complex.
Heather Henry, Queen's nurse and co-chair of the New NHS Alliance, says that the state of practice nursing has changed dramatically since she last practised in the 1990s. 'The workforce is shrinking, and more pressure is on practice nurses because of a lack of GPs,' says Ms Henry.
'Nurses are taking on enhanced duties that they may or may not be prepared for, and this can be stressful,' she says acknowledging that training for these duties can be variable.
Along with an increased caseload, nurses are loaded with 'bureaucratic and administrative burden' says Ms Henry, who cites the then NHS Alliance's work Making time in general practice. The report, produced with the Primary Care Foundation in October 2015, argues the national urgency of reducing red tape in general practice, and implementing improvements in individual practices. Bureaucracy and the 'drive to achieve targets fall heavily on practice nurses', says Ms Henry.
Unhealthy coping mechanisms
The care offered in general practice is 'much more sophisticated than it used to be,' says Kathryn Yates, primary care nursing lead at the Royal College of Nursing (RCN). It now offers 'more specialist services and the [practice nurse's] role has changed – it has become more dynamic,' she says. Making the most of your 10 minutes with each of the hundreds of patients visiting general practice each week (and often with more than one health condition) is a struggle. You spend most of your life at work, so if it isn't right it is going to have an impact on other parts of your life, she says.
Nurses, by the nature of the role, put the needs of their patients before their own. Debbie Brown, advanced nurse practitioner, CCG nurse consultant and editor-in-chief of Practice Nursing, says: 'There is so much tenacity in primary care and loyalty to the sector.'
'Practice nurses are acutely aware of their patients in the waiting room,' says Ms Brown. 'They have the greatest grit and determination'. But some health professionals are resorting to 'unhealthy coping mechanisms' to deal with their stress, suggests Mind's survey, which found that around two in five (42%) primary care practitioners drink alcohol at least once a week to cope with workplace pressure, while around one in 10 turn to smoking cigarettes.
'We must be mindful of the small number of people who responded' to Mind's survey and the range of professions questioned, says Ms Brown, as the sample may not be representative of the wider primary care nursing workforce, 'but we can't get away from the fact that workload is increasing'.
Ms Brown expresses concern that the isolated nature and criticality of practice nursing prevents nurses from sharing their worries about heavy caseloads. Mind revealed that 22% of primary care staff feel that 'disclosing that they are overly stressed would lead to them being perceived as less capable than other colleagues', while two in five (22%) felt that disclosure would count against them when being considered for promotion.
Admitting that you're struggling with your workload can be difficult, and if your practice manager is your employer 'you may not feel you can be honest with them and say how you really feel,' says Ms Brown, who stresses the need for every practice nurse to build a support network outside of their practice. 'Find the lead nurse at your CCG, access community education provider networks (training hubs), think about becoming a Queen's nurse, join your Nurse Forum, join the RCN –many nurses left when there were changes regarding indemnity, but the RCN does more than that.'
Ms Brown also stresses the value of building online relationships using Twitter and getting involved with
@WeGPNs, where you'll learn that you're not suffering alone. 'We need to start speaking up and saying how we're feeling, otherwise nothing will change,' she says. 'If we always do what we've always done, we'll always get what we've always had.'
Practice nurses are 'happy to provide care to a patient, or refer them to a specialist, but they may find it difficult to admit their own problems,' says Ms Yates. It's high time practitioners are able to discuss their mental health issues without feeling ashamed; health workers need access to health care just like the general public. Acceptance of poor mental health is slowly growing – Time to Change, the campaign to end mental health discrimination, last year reported that 2.5 million more people had favourable attitudes to people with mental health conditions than three years before – but there is still some way to go to overturn the stigma. Seeking help for mental health issues can only improve staff wellbeing, and ultimately, the health outcomes of patients.
Piloting wellbeing schemes
The General Practice Forward View published in April 2016, sets out to address these issues with a 'multi-billion pound investment to stabilise and transform general practice'.
The Forward View, developed by NHS England, presents plans to launch a £40million practice resilience programme and promises £16million for 'free, confidential local support and treatment for mental health issues, supporting GPs who are at risk of suffering stress or burnout'.
NHS England has promised a practice nurse development strategy, and £15billion investment in improving training capacity, increasing the number of pre-registration placements, improving retention and supporting nurses returning to work. But where is the service for nurses struggling with workplace stress?
Schemes for nurses are in the pipeline and will be piloted this autumn, says Ellen Nicholson, advanced primary care practitioner at City and Hackney GP Confederation and Queen's Nurse. 'NHS England have been doing work around wellbeing for secondary care, but they found these schemes don't work for primary care,' says Ms Nicholson.
The project will provide 'opportunities for discussing significant events and raising concerns, training to deal with difficult patients and bullying, and managing stress,' says Ms Nicholson. As well as providing preventative interventions for mental health and improving culture, the project aims to address physical health issues with physiotherapy, weight management schemes, and incentives for taking part in physical activity.
'The most important aspect of our offer is that it will be open to all staff working within a practice,' says NHS England, but Ms Nicholson is clear that 'these schemes have to work for practice nurses. If it's too onerous, it's not going to work.'
Perhaps nurses could benefit from the latest wellbeing trend: mindfulness. But, as GP Margaret McCartney puts it in her No Holds Barred column in The BMJ , 'taking time to relax, talk to colleagues, think, and reflect is part of humanness'.
The strain on primary care is 'symptomatic of a much wider issue,' says Ms Yates, 'and it affects our colleagues working in secondary care too'. Being mindful of your symptoms may help stress in the short term, but wellbeing interventions cannot be a long-term fix.
The practice nursing workforce is ageing, but the 'older nurses are holding on to support the next generation,' says Ms Henry, who is worried that these problems may deter the right people from entering primary care. 'We think practice nursing is fantastic,' she says. 'Do not be put off by the pressures in primary care – embrace them.' Can the general practice nursing strategy alleviate these pressures? Its publication can't come soon enough.
Key findings of Mind's stress survey of 1000 primary care staff
Stress and mental health problems
88% of primary care workers find their work life stressful.
43% said workplace stress has led them to resign or consider resigning from their jobs.
21% said stress in their job has led them to mental health problems.
8% said workplace stress has led to suicidal thoughts.
17% said stress led them to take medication for mental health problems.
83% said their stress affects their ability to sleep.
54% said their stress has a direct impact on their physical health.
17% said their stress has led them to call in sick to avoid work.
42% drank alcohol at least once a week to cope with pressure.
8% smoked every day as a way of coping with the pressure.
Disclosing stress
31% felt that telling someone they are overly stressed would lead to them being perceived as less capable than other colleagues.
22% felt that disclosing their stress would count against them when being considered for promotion.
Abigail James, freelance health writer
1. Mind finds 'Worrying' levels of stress among primary care staff. Mind. 2016. http://www.mind.org.uk/news-campaigns/news/mind-fi...
2. General practice in the UK – background briefing. BMA. 2016. https://www.bma.org.uk/-/media/files/pdfs/news%20v...
3. Making time in general practice. Primary Care Foundation and NHS Alliance. 2015. http://www.nhsalliance.org/wp-content/uploads/2015...
4. Latest survey shows public are less likely to discriminate against people with mental health problems. Time To Change. 2015. http://www.time-to-change.org.uk/news/latest-surve...
5. General Practice Forward View. NHS England. 2016. https://www.england.nhs.uk/wp-content/uploads/2016...
6. No Holds Barred: Mindful of mindfulness. Margaret McCartney. BMJ 2016;352:i839
uploads/2016/04/gpfv.pdf. http://www.bmj.com/content/352/bmj.i839
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