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Abstract
Aims and objectives To explore what wellbeing means to medical and nursing staff working in a large paediatric intensive care (PIC).
Design Exploratory qualitative design using an appreciative inquiry framework.
Setting PIC unit; primary, secondary and tertiary.
Participants 46 nurses and doctors working on PIC.
Interventions A set of images were used together with open-ended questions to prompt staff to discuss what wellbeing means to them. Interviews were audiorecorded and transcribed. Data were analysed thematically.
Results Images depicting nature, children and groups of adults were selected most. Meanings of wellbeing for PIC staff can be understood through three themes: (1) Being nurtured and supported at work, (2) Importance of nature and (3) Social support independent of work. The first theme considered the importance of being listened to at work as well as staff highlighting the value of being in control at work. Within the second theme, being active in nature and outdoors as well as the importance of being in the present moment was illustrated. Within the final theme, staff expressed the value of having support independent of work and highlighted the importance of spending time with family.
Conclusions This study provides a unique insight into how individuals working in PIC experience wellbeing and what wellbeing means to them. Understanding how healthcare professionals in PIC settings experience wellbeing and what wellbeing means to them will enable researchers to develop interventions designed to enhance staff wellbeing based on lived experience.
- paediatric intensive & critical care
- qualitative research
- paediatric intensive & critical care
- COVID-19
- organisational development
Data availability statement
No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- paediatric intensive & critical care
- qualitative research
- paediatric intensive & critical care
- COVID-19
- organisational development
Strengths and limitations of this study
Wellbeing is a nebulous concept. The use of images can help prompt healthcare professionals think about what wellbeing means to them.
Appreciative inquiry is a flexible framework which facilitates the use of imagination and ‘dream talk’ in the development of ideas for future resolutions without constantly being halted by the obstacles of the everyday.
This study was conducted in one paediatric intensive care unit in the UK. This means results may not be transferable to other paediatric intensive care units either in the UK or beyond.
Introduction
Staff wellbeing in paediatric intensive care (PIC) is a significant problem globally.1–4 There has been a large body of research conducted cross-sectionally1 2 4 5 examining the rates of burnout, all of which echo the finding that staff wellbeing in PIC is a significant problem that urgently requires a solution. Despite this, there is a paucity of evidence about what wellbeing means to staff working in this setting and little research into possible interventions to mitigate against burnout and compassion fatigue in this highly stressful environment.6 7
The term ‘wellbeing’ is defined by the Oxford English Dictionary as ‘the state of being comfortable, healthy or happy’ (Oxford English Dictionary 2021). Nevertheless, it is an equivocal and intangible concept open to subjective interpretation. Researchers have tried to conceptualise welbeing as a state of balance which is affected by life events or challenges.8 Wellbeing as a term is often used in relation to both physical and psychological (or mental) health. Within the UK there has been a growing drive to enhance staff wellbeing in health and care professions.9–12
This study is part of a larger programme of work exploring staff wellbeing. Our hypothesis is that the reduction, and even prevention, of staff burn-out, compassion fatigue and moral distress relies on the improvement and maintenance of staff wellbeing, alongside mandatory clinical competence and fitness to practise requirements. To improve staff wellbeing, we first need to examine what it means to them, how they experience it, and what they would need to improve their wellbeing at work. To achieve those goals, qualitative methods were the most appropriate for gaining insight into individuals’ subjective interpretations and lived experiences of wellbeing. In short, the present study aimed to understand what wellbeing means to individuals working in PIC.
Methods
Design
This study adopted an exploratory, qualitative design using appreciative inquiry (AI). AI is a methodological approach used to encourage exploration and discussion around a particular topic area.13 14 The five key principles of AI are: to be positive, constructionist, poetic, have simultaneity and be anticipatory. These principles allow individuals the freedom to explore a scenario through reflecting on its positive aspects while wondering about what could be possible in the future. This prevents people who want change from being blocked by practical boundaries at the first hurdle and instead fosters an open-minded, ‘outside the box’ mode of thinking where aspirations can be identified without judgement. Change can raise anxiety levels and often individuals feel a lack of free will to effect change because the system in which they work is experienced as static and unchangeable, which is common among those working in healthcare.15
AI adopts the positive stance that in every system something does work well, and every system contains some aspects that make it vital, effective, and successful. AI is also future-focused with its emphasis on generativity and pro-activity and has been evidenced alongside positive feedback to have an impact on clinical outcomes.16 As such, AI facilitates creativity through collaborative thinking and produces realistic solutions to what previously were conceived as insurmountable problems. The method takes you through a process to effect organisational change through the cycle of discovery, dreaming, designing and destiny.13 In this study, we drew on the discovery aspect: (1) identifying strengths of the current approach to wellbeing; and the dreaming aspect: (2) identifying what may work well in enhancing wellbeing in the future.
Sample
This study was conducted at a 31-bedded PIC unit (PICU) in the UK. Convenience and purposive sampling were adopted to ensure that all eligible members of medical and nursing staff had the opportunity to participate and that we accessed individuals with different levels of qualification and experience. Individuals were required to provide informed consent to take part and to have the AI session audio recorded.
Procedure
All eligible staff were invited to participate through email invitations, posters on the unit and invitations on staff social networking sites. Staff were also able to approach the research team based on the unit (RM and SW) to volunteer at any time during a shift. These shifts included day, night and weekends during the study period to ensure all staff had the opportunity to participate should they wish.
Semistructured interviews using the AI approach were conducted on the unit (with RM and SW) or by researchers independent to the unit (IB and OB). Some interviews were conducted face-to-face on the unit. The remainder were conducted remotely via Zoom video software, given that this study ran from December 2020 to February 2021 during the COVID-19 pandemic when researchers external to the hospital were not permitted access. The semistructured interview schedule was designed with AI principles and asked individuals to describe what wellbeing means to them. A set of 24 publicly available images were used to (online supplemental files (http://www.myhomelife.org.uk/) to help generate discussion of what wellbeing looked like for them and dreaming about how wellbeing might be improved in the future. The images are generic, including people, animals, objects and landscapes and were designed to evoke a range of emotions and reactions in people. Recruitment ceased once data saturation had been reached. All interviews were audiorecorded, transcribed and stored on a secure drive online. Identifiable information was removed to protect participants’ anonymity.
Supplemental material
Data analysis
A content analysis of frequencies of images identified as representing wellbeing was conducted. Inductive thematic analysis of interview transcripts was conducted in which themes were led by the content elicited from participants.17 18 Our focus was to explore the rich data generated rather than building on pre-existing theory.
Quality and rigour
The study conduct was guided by the Equator Standards for Reporting Qualitative Research (https://wwwequator-networkorg/reporting-guidelines/srqr/) and we also drew on Yardley’s19 criteria for good quality qualitative research . The research was sensitive to context in its prioritisation of participant voices and its focus on PICU as a highly pressured working environment; the study authors were committed to producing rigorous research by documenting and discussing process throughout data collection and analysis. and have been transparent in the reporting, offering a coherent account of the meaning of staff wellbeing; and the work is situated within a need to make positive impact on staff wellbeing, which is identified as of primary importance to the mental health of healthcare professionals and the delivery of good quality care.
Patient public involvement
Key stakeholders were involved in the conceptualisation of the study. We invited representatives from the nursing and medical staff groups to provide feedback on the design of the study and the methods used.
Results
Forty-six individuals participated in this study; of these 39 were female and 7 males; 35 were nurses and 11 doctors. Interviews lasted between five minutes and one hour and ten minutes.
The content analysis of images showed that the most popular images were of nature, a child being thrown playfully in the air, people being together at the beach, a person diving into the air about to go open-water swimming, and an image of a plant growing in the palm of someone’s hand (see figures 1–3).
Five most popular images—shown in order of popularity.
Five least popular images—shown in order of popularity.
Overall frequency of each of the 24 images.
The themes identified were: (1) Being nurtured and supported at work; (2) The importance of nature; (3) Social support independent to work.
Theme 1: being nurtured and supported at work
Individuals valued feeling supported at work, which was often represented by being listened to. Listening was defined as reciprocal in terms of wellbeing; it is helpful to the person speaking but also to the person listening. Staff identified the significance of ‘an open-door policy’ (Participant 1021) and that management were non-judgemental when listening to staff (Participant 1043).
One participant also noted the ‘joy’ that is possible in a work environment that actively listens. It is not simply listening to one another, but the satisfaction experienced through the collaborative effort. Joy was explicitly expressed by participants as a key emotion experienced through being listened to. Similar to the expression of joy, the concept of witnessing and experiencing growth through work was significant to some individuals.
“For me that shows trust erm it shows people listening there is joy in what I see,
cos I thought it represented, you know, sort of hard work but also that you’ve kind of achieved something, like growth from the work that you’ve done’ (Participant 1003, image 4)
A strong sense of team identity and being cared for by that team was essential to wellbeing for Participant 1017. For them, wellbeing was fostered by being a part of a larger whole and being able to flourish while being supported—in the palm of a hand —(image 4) of the wider team.
“Erm I’m going to choose image 4 which is a picture of a tree in somebody’s hand. For me it represents the team having me in their hand and it represents erm that you need to be rooted with yourself and your team, erm …and the team provides for me, and by the team I mean the whole wide team, not just the leadership team” (Participant 1017, image 4)
Another participant identified the same image and drew out the creativity within the growth of that tree; for this participant, creating something new represented wellbeing. Participant 1033 commented on this with reference to wellbeing as the product of creating something new. Creativity is important to individuals’ wellbeing. Outside the workplace they engaged in creativity by exploring new hobbies and projects.
“I liked number four, cos I thought it represented, you know, sort of hard work but also that you’ve kind of achieved something, like growth from the work that you’ve done, and I like that, sort of, you know, creating something new, I think can be wellbeing at work and at home as well, you know, being creative, whether that’s like making a cake, or doing gardening, that kind of thing, or at work when you’re trying to do things differently and do new projects.” (Participant 1033, image 4)
For some individuals being in control at work helped boost their wellbeing. Being in control gave them a sense of autonomy which elicited a sense of good wellbeing. For one participant, this was illustrated through applying for flexible working hours to suit their lives.
‘I reduced my hours…. but having some consistency has really, really made an impact on my relationship, my home life, my reset.’ (Participant 1040).
Individuals highlighted the role of team at work and being supported. This was likened to an orchestra with everyone playing their role in the smooth playing of the orchestra. Wellbeing is to this individual when things are controlled well.
“And I thought number twelve, but it’s like, I thought like the image was about control and precision, and that wellbeing, I like being… And I thought it was like conducting, and I think actually it feels a little bit like we’re conducting at work when we’re there, sometimes like quite a big, crazy, chaotic orchestra, and so I think wellbeing for me is when I feel that maybe I’ve controlled things well and conducted things well.” (Participant 1033)
The metaphor of the orchestra perfectly represents the aesthetic Gestalt, the joy, of collaborative working and team membership. When the team is functioning and performing well, there is a feeling of satisfaction. Despite, and perhaps because of, the complexities and challenges of work on PICU, when all goes well in the team, a feeling of authenticity is engendered, which brings with it a sense of wellbeing. Support is essential, but these participants are identifying something more than that; it’s a sense of togetherness and mutual nurturing which fosters good wellbeing.
Theme 2: importance of nature
Being outside in the open space was identified as having a positive impact on individuals’ wellbeing. For most, this represented being in a different place to their usual working and living environment.
For one staff member, the image of nature elicited thoughts about walking their dog:
‘Image 21 this makes me think of my dog and taking him for a walk and being calm and spending time with him.’ (Participant 1025).
Another participant gave a rich, sensuous description of why nature was so significant to their wellbeing.
“Image 14 it’s like a wild field and the scent and the smell and the whistling of the wind through the flowers and the daffodils. Again, this is just brings you right down from your normal day’s work, or your normal environment and the silence is beautiful and sometimes the hum of a bee that buzzes through the flowers as it’s in search of its nectar and really, really gives you that beautiful feeling of wellbeing”(Participant 1031)
As well as offering this immersive feeling of being in a different place, being away from work with only the smells and sounds of fauna and flora, one participant reminded us that this ‘natural experience’ need not be complicated:
simple times can be just as important for your, for your wellbeing as well.” (Participant 1037). Just being able to be outside and breathe in fresh air may be enough.
simple times can be just as important for your, for your wellbeing as well’ (Participant 1037). Just being able to be outside and breathe in fresh air may be enough.
For other participants, nature brought with it a sense of stillness and an opportunity to be alone, prompting reflection, which was essential for good wellbeing.
[image 18]With the raindrops on a puddle lake, all those moments where you can sort of sit and reflect” (Participant 1030)
I actually like solitude in wellbeing, wellbeing is about being outdoors, it’s about being in nature, it’s about vegetation, it’s about the sea, it’s about the mountains and that is where I would go for rest and relaxation.” (Participant 1028)
The significance of nature was embedded in staff perceptions of wellbeing. For those who chose images based in nature it represented an opportunity to be away from the work environment, to be alone, still, and distracted from the sights and sounds of PICU.
Theme 3: social support independent to work
Individuals described how having support from family members and friends outside of work was helpful in managing their wellbeing. They offered a safe space to discuss work, even if, or for the very reason that, these individuals do not understand what happens at work. Friends and family external to the unit provided a useful a buffer between work and home life:
My friends outside of work and socialising and stuff helps with my wellbeing.” (Participant 1008).
For others, the images reminded them that family were important and performed an essential part of maintaining their wellbeing:
“Reminds me holding onto my family and things like that which all help with my wellbeing” (Participant 1006).
Participant 1024 described how they would actively seek out friends and family if their wellbeing had been threatened by something at work:
“I think it looks like a group of friends or family and that represents wellbeing to me just because, I don’t know that makes me feel happy and if I’m feeling down and I want to improve my wellbeing I just turn to my friends or my family” (Participant 1024)
Similarly for participant 1026, the image of holding hands represented the support and comfort they would receive from their parents in times when wellbeing was low.
It feels like somebody’s listening to you if they’re holding your hands particularly in that way and I suppose the older hands as well just represents for me would represents my parents which is who I would talk to if I was struggling with anything and they bring me comfort”(Participant 1026)
Having a supportive family and friends’ network, which looked different to each participant, was experienced as a necessary counterfactor to the highly stressful clinical environment of PICU. Family and friends clearly provide a source of comfort, distraction and a sounding board to individuals, which helped restore and maintain participants’ wellbeing after it had been challenged at work.
Discussion
AI and a series of images were used to determine from staff working in PIC what wellbeing means to them. Their accounts gave us a clear indication of the constituent elements of wellbeing as experienced by them. The first of these was nature. PIC staff working in a busy city-centre hospital chose images of green and blue spaces to represent wellbeing. In the last 10 years there has been a surge of research suggesting that nature is good for wellbeing.20–22 Recent research has further promoted the concept of ‘forest bathing’23 and the potential benefits of immersing oneself in nature. The results from this present study further support these findings. In addition, participants valued being in a still, quiet outdoor environment, perhaps the perfect antidote to working in a busy PICU.
Research evidence not only promotes the importance of ‘being in’ nature but also ‘being active’ in nature such as walking or cycling.24 25 Like Utz,26 participants stated how having a purpose in nature whether that be swimming or walking a dog helped boost their wellbeing. Thus, this research has corroborated existing evidence that nature is a clear constituent of the lived experience of wellbeing for staff working in PICU.
Another essential characteristic of wellbeing for the participants was a strong sense of collaborative working, of being nurtured by team members at work. Participants experienced wellbeing when they were included in the wider team, were listened to by team members and management, and were successfully functioning as a part of a wider whole. Being listened to at work meant individuals felt they were able to grow and seek support when needed. This corroborates existing evidence that feeling listened to is good for an individual’s wellbeing.27 In a culture which speaks more than listens it is crucial that we learn to listen to others. Research has shown that listening is a method of addressing psychological distress that is central to healthcare.28 29 Furthermore, individuals stated that being in control at work engendered an embodied sense of wellbeing through the development of self-efficacy30—being confident in one’s own ability to perform a task—represented by the harmony one might generate in an orchestra. This was especially pertinent for participants who required the ability to be in control in a particularly stressful environment. Previous research has evidenced that having autonomy over a situation at work is beneficial to an individual’s wellbeing.31
The final characteristic of wellbeing we identified in this focused study, was the social support network provided by family and friends. Research has unequivocally found that having support networks from a wide range of sources is beneficial to an individual’s wellbeing.32 33 The participants described how having a support network of people to turn to who are independent of their work situation was key to restoring good wellbeing when it had been threatened by something at work. This freedom to ‘off load’ to independent others is a key finding that echoes evidence from previous research34 35 that having a person to talk to is central to wellbeing.
The findings resonate strongly with Maslach’s work on burnout, which has identified professional autonomy, self-efficacy and being in control as key ingredients for better job engagement which could therefore also be protective against burn-out.36 The self-determination theory37 also offers strong support to our findings. In this theory, autonomy, competence and relatedness are identified as basic psychological needs which, alongside intrinsic and extrinsic motivation, are mediators of health and wellbeing at work. PIC staff’s sense of being nurtured and their strong team identity demonstrate the significance of relatedness, feeling connected to others at work. Through these strong team connections, a culture of growth can be established which will enable staff to flourish, thus establishing high levels of self-efficacy. In turn, a workplace which fosters high levels of competence and feelings of connectedness will create a staff group who are able to practise autonomously. In short, for PIC staff wellbeing to be improved and maintained there is a need to focus on creating positive workplace cultures that foster strong peer relationships, encourage staff to thrive, and trust their staff to practise autonomously.
Strengths and limitations of the study
Although data were collected during the COVID-19 pandemic, it did not feature strongly in participants’ accounts. This is an indication of the strength of the method. By using images individuals were encouraged to literally picture their wellbeing and in doing so, they were transported away from their current context for a short time, while they imagined engaging in wellbeing-supportive activities. The other simple strength of this work is that it focuses on how the problem of burnout may be addressed by turning towards solutions. Furthermore, our definition of wellbeing is grounded in lived experience, which is a necessary starting point for understanding this otherwise nebulous concept.
This study was focused on a single site, which may mean results are not transferable to other settings. It also took place during a pandemic, which may have influenced findings. While it is worth repeating this work in the future and in different locations, we are encouraged by existing evidence, that there are likely to be similarities with other healthcare settings, whether in PICU or adult intensive care units, or other hospital settings.
Conclusion
This study has learnt from PICU staff’s lived experience that wellbeing can be restored by spending time with family and friends; wellbeing at work is reliant on a healthy, communicative and collaborative team; and that being outdoors, in nature, away from the work environment, whether active or still, provides the perfect circumstance to improve and maintain one’s wellbeing. With this knowledge we can build these constituents of wellbeing into interventions designed to improve healthcare staff workforce wellbeing.
Future recommendations for practice
We have demonstrated that interventions to improve PIC staff wellbeing need to focus on some key elements: team identity, connectedness, support from peers, family and friends, giving staff space and language to identify what wellbeing means to them, and providing opportunities for wellbeing-supportive activities.
First, we recommend a brief intervention: show staff the image cards and ask them: which card represents wellbeing to you and why; how does it make you feel; what will you do in the next 2 weeks to make that feeling a reality? This may only need 10 minutes, but as well as giving staff a rudimentary understanding of their own wellbeing, it will provide them with a brief plan on how to enhance it, and by taking part in the activity their wellbeing will be improved.
Second, we recommend units engage with local social prescribing services. This will facilitate the provision of information and resources for activities, groups, places, which offer wellbeing-supportive activities that staff may otherwise not have known about. This is especially helpful for staff new to the country or area.
Third, we recommend setting up small peer support groups. This will help engender that team identity, a sense of nurturing, and will lay the foundations on which autonomous practitioners will be developed.
Fourth, we recommend researcher–practitioners consider using AI in their own research. It offers an approach founded on lived experience and creativity which breaks through perceived and real boundaries to fully explore positive routes for organisational change.
Recommendations for future research
This research has offered a working definition of wellbeing and the starting point for simple interventions to improve staff wellbeing. The questions which remain unanswered are whether those interventions will improve wellbeing and reduce burnout and moral distress. This calls for feasibility work to determine whether a randomised controlled trial of a wellbeing intervention would produce those outcomes. Future research also needs to demonstrate the potential links between staff wellbeing, staff retention, sickness absence, and their relationships to patient experience and outcomes. Intervention development and feasibility work are required to determine appropriate outcome measures and to establish evidence of effectiveness and cost-effectiveness of improving staff wellbeing.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study was reviewed and approved by a central NHS ethics committee, Health Research Authority (20/HRA/3817) and Aston University (AHRIC 003-2020 RS) and was conducted between October 2020 and February 2021. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors wish to thank each individual who kindly took part in this study.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @MorrisonRacha, @littlesarahwebb, @RAPIDIndex, @drrachelshaw and @swell_staff
Contributors RM, RS, SW and HD conceptualised the study. RM, SW, RS, OB and IB oversaw and engaged in data collection. IB, RM, RS, SW, HD and OB contributed to data analysis and the writing and revising of the manuscript. RS is responsible for the overall content as guarantor.
Funding This work was supported by Birmingham Women’s and Children’s Hospital Charity Paediatric Intensive Care funds, Ref: 37-6-124.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.