Article Text

A qualitative evaluation of weekly reflective practice sessions for the intensive care unit pharmacy team during the COVID-19 pandemic
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  1. Naima Fowlis1,
  2. Nina Barnett2,
  3. Sara Banks3,
  4. Barry Jubraj4
  1. 1Psychology, Royal Holloway University of London, Egham, UK
  2. 2Care of Older People, NHS Specialist Pharmacy Service, England and London North West Healthcare NHS Trust, Middx, UK
  3. 3Northwick Park Hospital, Harrow, London, UK
  4. 4UCL School of Pharmacy, University College London, London, UK
  1. Correspondence to Naima Fowlis, Psychology, Royal Holloway University of London, Egham TW20 0EX, UK; naima.fowlis{at}nhs.net

Abstract

Despite well-being initially being high on the agenda for UK health organisations, the COVID-19 pandemic has highlighted significant gaps around provision for well-being of pharmacists in the UK. The COVID-19 intensive care unit (ICU) environment exposed pharmacists to mental, physical and emotional challenges, including high levels of patient mortality.

Objectives To provide an account of the experience of pharmacists working within an ICU at a large National Health Service hospital who attended reflective practice sessions throughout the first wave of the pandemic.

Method A retrospective, cross-sectional design was used to gather information from eight participants who had attended nine, 30-minute weekly reflective practice sessions. Participants were invited to complete a 10-item online self-report questionnaire. The responses from the questionnaire were analysed using theoretical thematic analysis.

Results Seven participants completed the self-report questionnaire. Thematic analysis of responses identified four themes: (1) permission: both professional and personal ‘permission’ was necessary for participants to be present for the reflective practice sessions and to attend to their own well-being; (2) containing safe space: reflective practice sessions offered a consistently secure environment from which to explore topics which created challenge, personally and/or professionally; (3) connectedness: the impact of these sessions on participants’ relationships with other attendees, as individuals and the group as a whole; and (4) emotional experience: increased awareness of developments around their expression, processing and management of emotion as a result of attending the sessions.

Conclusions This study provides new and important insights into the use of reflective practice for pharmacists working in an ICU during the COVID-19 pandemic. Findings demonstrate heterogeneity in the experience of distress, the need to support the pharmacy profession, and the need to provide opportunities for staff to connect safely with colleagues during such crises. The impact of organisation-led support for the pharmacy profession is discussed as a future direction of research.

  • COVID-19
  • PHARMACY SERVICE, HOSPITAL
  • MENTAL HEALTH
  • Quality of Health Care
  • Workforce

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Introduction

With a backdrop of a growing climate crisis, global pandemic, politics and actions that have increased awareness of the impact of differences in race and ethnicity, the term ‘well-being’ has become part of society’s and individuals’ daily vocabulary. In the UK, well-being was high on the agenda for healthcare organisations1–3 before the global pandemic. The link between the well-being of healthcare staff and patient care quality, patient experience and clinical outcomes is well established.4–6 Research suggests that there is a high prevalence of psychological morbidity among clinical and non-clinical staff working in the National Health Service (NHS),7–9 accounting for one-third of all sickness absences and costing approximately £1 billion in 2015.10

The effect of the pandemic on the emotional well-being of clinical staff has become highly topical.11 12 The format of interventions suggested and implemented has ranged from Schwartz rounds and Balint groups to employee assistance programmes and psychological support through employers.13 Formal support for the well-being of pharmacy staff is not embedded in most pharmacy practice settings, nationally or internationally; however, the particular needs and impact on this staff group have been highlighted during the COVID-19 pandemic.14 It has become clear that, in common with other professions,15 16 supporting the emotional well-being of pharmacy staff at the front line of the COVID-19 pandemic has served to maintain the mental health of staff and been a critical aspect of effective patient care.The International Pharmaceutical Federation produced guidelines for pharmacists in the management of COVID-19. However, no reference was made about the impact of such work on the well-being of the pharmacy workforce in contrast to guidance for other professions.17 18 It is within this context that pharmacists at London North West University Healthcare NHS Trust (LNWUH) were working when the COVID-19 pandemic arrived in the spring of 2020.

This paper provides an account of the experience of pharmacists working in intensive care units (ICUs) at LNWUH who were able to access group reflective practice sessions during the COVID-19 pandemic. It provides a qualitative evaluation of participants’ experience of these sessions, explores the benefits of reflective practice as an intervention under such unique circumstances, and goes on to discuss the well-being of individual pharmacists, the profession more generally, and whether the principles and undertaking of reflective practice may continue to benefit the profession in the longer term.

Materials and methods

Design

A retrospective cross-sectional study design was used.

Setting

Northwick Park Hospital was one of the first acute hospitals in the UK to receive large numbers of patients with COVID-19 at the start of the pandemic. The surge in patients admitted with COVID-19 in March/April 2020 led to the bed capacity of the ICU being increased from 22 to 68. Early leadership was provided by clinical psychologists based in ICUs, acute hospitals, and by others specialising in occupational health; they were the first to recognise what staff were experiencing, and worked with organisations (Association for Clinical Psychologists, British Psychological Society, Intensive Care Society) to develop and disseminate guidance to support staff over the short, medium and longer term, at individual and group level and organisation-wide.

Participants

At LNWUH, pharmacists were redeployed from other specialities to work in the ICU in patient-facing roles at the bedside. Rapid upskilling was required to expand their clinical knowledge to manage COVID-19 patients in this new, unfamiliar setting. Pharmacists undertook their role wearing full personal protective equipment (PPE), became familiar with the practicalities of donning and doffing (putting on and taking off) PPE, and did so while managing concerns for their own health and the fears of their loved ones, many of whom did not want them to come to work. Following high levels of patient mortality at the start of the pandemic, the mental, physical, and psychological challenges provided the context for one of the authors (NB) to meet with the lead ICU pharmacist and for both to recognise that all ICU pharmacists, both regular and redeployed, were in need of well-being support. The full expanded ICU pharmacy team, consisting of eight pharmacists, were invited and later participated in the reflective practice sessions.

Intervention

Author NB rapidly established a response to this need in the form of brief reflective practice sessions. The aim of the sessions was to provide time (no more than 30 min) and space (weekly) for ICU pharmacists to share their feelings about their experiences of working during the pandemic and to support each other to develop team cohesion and trust. These were, in short, mini reflective practice sessions. The format and process of the group took components of Schwartz Rounds19 and Balint groups20; see Procedure section for further details. In total, nine reflective practice sessions were facilitated by author NB between 8 April to 8 June 2020.

Materials

Sessions were primarily via Zoom or via a mobile phone on loudspeaker if the Trust WiFi connection was poor. To support the validity of the intervention the facilitator of sessions (author NB) received weekly supervision from one of the authors (BJ, a pharmacist and trained counsellor) and monthly supervision from another author (SB, a consultant clinical psychologist working at LNWUH). These supervision sessions also served to support the facilitators’ own emotional well-being, acknowledging the potential impact of hearing and working with the experiences shared by participants during the meetings.

Measures

After nine reflective practice sessions had been held, participants were invited to complete a self-report questionnaire using SurveyMonkey. This evaluation was performed by one of the authors (BJ) who had no part in the sessions. Although surveys are commonly used in quantitative research, they have legitimately been used for qualitative studies21 22 even in instances where responses have been brief.23 Ideally, semi-structured qualitative interviews would have been undertaken for this work to explore themes that arose from related literature that may have had relevance and congruence with the experiences of the ICU pharmacists; however, the time and resource constraints of practitioners engaged in patient-facing activities precluded this. Elements of action research were present in this work as participants shaped the work through influencing the structure and content of the sessions and then completing the questionnaire.

The survey (online supplemental appendix 1), developed by authors BJ and NB with support from the lead ICU pharmacist, comprised 10 open-ended questions, selected to better understand participants’ experience of attending the sessions, including its outcomes and impact, personally and professionally. The survey link was distributed via an email from author NF on 9 June 2020, with participants asked to submit their responses by 30 June 2020. This advised participants of the purpose of the survey and confirmed that responses would be anonymous with no identifiable data. By completing the online self-report survey, participants implied their consent to participate in the service evaluation.

Procedure

The meetings were typically held towards the start of the working day, around 9 am. The facilitator introduced the sessions by asking each participant in the group, if they wished, to share briefly how they were feeling that day, with perhaps one word or a short statement. The facilitator then invited participants to consider if they would like to share an experience from the previous week that had challenged them. One participant was then given the opportunity to share their experience without interruption or comment from the facilitator or wider group. Once finished, the full group was asked to sit quietly for 1 min to reflect on what they had heard. Then other participants were invited by the facilitator, one by one, to share how what they had heard made them feel, what it made them think about, and how it resonated with them. Participants were able to offer their reflections in any particular order and for an undetermined amount of time. If they wished, participants were free not to respond.

The facilitator actively listened to what was shared by participants, acknowledged, paraphrased and summarised what had been heard, at points shared her own reflections for the group to consider, and then left the space open for another participant to share. Towards the end of the session, the facilitator invited the participant who had first shared their experience to respond to what they had heard and to reflect on this in relation to their learning, future practice and well-being. To close, the facilitator invited each participant to again say how they were feeling and to talk about what they were going to do next in their day.

Theoretical basis for intervention

Free-text comments from the survey were analysed using Braun and Clarke’s24 theoretical thematic analysis framework under an inductive data-driven approach,25 with themes being drawn from the content of the comments. The ‘six-phase’ framework24 26 was applied to our service evaluation and this is described in online supplemental appendix 2. Data saturation was reached at the point of ‘thematic exhaustion’ (page 65), as defined by Guest et al,27 at the point in which no new codes were identified in the data.28 Researchers NF and NB used this method, consistent with the concept of saturation, as ‘information redundancy’29 during data analysis.

Results

A total of seven participants responded to 10 questions (see online supplemental appendix 1). The seven participants completed the online self-report survey with <1% of data missing for responses to the 10-item survey (68 responses were received out of the total 70 possible answers). The 68 responses ranged in length from one to three sentences. These were then coded and organised into themes and then 53 subthemes (online supplemental appendix 3). Results were not collated in relation to gender, age, level of experience, and additional specialisms as this was a small qualitative pilot study. From this analysis, four overarching themes were identified: (1) permission (personally and professionally), (2) containing safe space (a confidential, supportive environment in which to have conversations with high emotional content), (3) connectedness, and (4) emotional experience (awareness, expression, processing, and management of emotion).

Theme 1: Permission

Statements within this theme related to the various ways in which permission, both professional and personal, was necessary for participants to be present for the reflective practice sessions and indeed for participants to attend to their own well-being. Participants repeatedly referred to the need to ‘be allowed to take time out’ of their schedules and the need to ‘slow things down’ to fully benefit from what was being offered. Having time allocated to this practice by line managers was essential in this respect. For some, personal permission represented a barrier to attending the reflective practice sessions for example, setting intentional boundaries between work and non-work time, and opting to have ‘a COVID-free day’.

Theme 2: Containing safe space

Participants’ responses within this theme were centred around the way in which reflective practice sessions offered a consistently secure base from which to explore topics which created challenge, personally and/or professionally. Statements within this theme identified the skills of the facilitator as being key in creating and maintaining the setting for reflective practice to be undertaken, particularly with regard to managing the group dynamic, variation in active participation within and across sessions, and responding to uncertainty or emotional distress.

Variation in participants’ experience of distress and the extent to which they were used to and comfortable sharing this with colleagues, in a group setting, were evident. One staff member commented that the structure and support provided within the sessions allowed for this in a way that would not have been possible in other forums offered for the profession or by the organisation. Another noted that individual differences were respected and accommodated by all involved in the sessions, such that attendees were able to ‘share at their own pace and comfort’. In contrast to these experiences, one participant stated that they felt uncomfortable talking about their feelings in front of others.

Responses to the survey provided an indication of the positive consequences of the reflective practice sessions for staff members. One attendee shared that the experience had increased their trust in colleagues. Another recognised their improved capacity to provide comfort to others ‘in the moment’ and to follow-up on this some days later as a result of what they had seen, heard and contributed within the sessions. Opportunities arising from the groups for modelling and practising verbal responses to others’ emotional needs seemed to be particularly important in increasing participants’ awareness of the well-being of others and their confidence in offering support within the limits of the pandemic, captured in one participant’s comment: ‘I (had) felt restricted as I couldn’t hug them’.

Theme 3: Connectedness

Statements within this theme related to the impact of the reflective practice sessions on participants’ relationships with other attendees, as individuals and the group as a whole. Responses suggested that the time and space provided by the sessions afforded participants the opportunity to learn about colleagues beyond the sphere of work. Repeated reference to ‘learning’ was not focused on knowledge associated with continuous professional development, or one or more attendees being placed in the position of expert for others to receive their experience or wisdom. Instead, these responses appeared to reflect participants’ value of their developing understanding about their colleagues at a more fundamental, human level, without hierarchy.

Participants felt unable to share the realities of their working environment with colleagues, friends and family. This was said to be in order to protect those who were unfamiliar or held concerns about the setting within which they were practising, contributing to the sense of solidarity within the group. This connectedness in turn seems to have generated a level of trust whereby participants felt they were actively supporting each other, beyond the reflective practice sessions. One respondent shared: ‘I think it helped us support each other during this difficult time’, and another: ‘I’ve been able to better help comfort other colleagues based on what I’ve learnt from these sessions’.

Theme 4: Emotional experience

Participants’ responses within this theme reflected increased awareness of developments around their expression, processing, and management of emotion as a result of attending the reflective practice sessions. Comments from participants included many statements about their emotional experience in relation to concerns of family and friends and, associated with this, their own sense of confidence in coping with the emotional impact of their work during the pandemic.

The benefits of participants being able to share their emotional experience within the reflective practice sessions, and the function of the sessions to allow some processing of this experience, appear to be core to this theme: ‘[It was] … really helpful as we could get various perspectives’, ‘I felt [….] appreciated, valued, relaxed and relieved’.

Discussion

Little has been written about supporting the well-being of pharmacists in crisis situations such as the COVID-19 pandemic in the UK. Author NB sought to work at a collective level and adapted existing approaches for addressing staff well-being, at pace, to meet an immediate need of pharmacists working in the ICU setting. Qualitative research exploring participants’ experience of this brief intervention has produced findings in line with other literature on group-based support for well-being of healthcare staff working during the pandemic.30–33

The importance that participants placed on awareness, expression, processing and management of emotion was a fundamental finding of this research; this is in keeping with the results of studies undertaken with healthcare staff during the severe acute respiratory syndrome (SARS) epidemic in 200334–36 and other studies on the impact of the COVID-19 pandemic on the well-being of healthcare staff.37–39

The first theme of permission provided further evidence of the importance of moving beyond understanding and supporting well-being at an individual level to recognising the potential for interventions to be organisation-led, especially when working to protect the psychological well-being of staff working in conditions of crisis.40 41 Participants’ responses suggested that there may have been a recognition that emotional, social and relational factors were central to working effectively in a pharmacy team and a degree of relief that colleagues in leadership positions were now also aware and actively supporting staff to speak about and address these issues.

The finding that a ‘containing space’, where participants felt psychologically safe to speak freely, was regarded by participants to be an important element of this brief intervention. A large number of responses suggested that attendees had already begun to consider the format and content of the sessions if they were to continue running, an indication perhaps of the satisfaction and hopes associated with reflective practice for individuals and the wider group. The Point of Care Foundation42 emphasises the need for individuals in leadership positions to understand, provide consistency for participants and facilitators who are actively supported to run reflective practice sessions, and to establish the necessary conditions for these interventions to be optimally effective.

The third theme, suggesting that pharmacists need to ‘connect’ with others experiencing similar challenges, is consistent with research highlighting the importance for healthcare staff to feel relationally safe within the context of their working environment.43 44

In relation to emotional experience, there was a somewhat unexpected effect of the reflective practice sessions, where participants appeared to have become more assured about their capacity to tolerate and manage their emotional needs, given that problem-solving or strategies to manage such challenges were not explicitly addressed within the sessions.

The concept of attending to personal well-being was provided informally but not routinely within the pharmacy at LNWUH. Anecdotally, this appeared to be reflected in other sectors of the pharmacy profession in the UK. The Wardley Wellbeing Service was developed in 2012 to meet the demand of offering support to pharmacists struggling with stress.45 Consideration is needed around how the above knowledge, principles and practices can be applied to develop a system-wide approach to supporting staff well-being, which is embedded within departments, services and teams. One of the authors (NF) worked during the pandemic to develop an online video resource which was designed to support managers with staff well-being conversations.46

Guidance published by the National Institute for Health and Care Excellence highlights organisational approaches that are both preventative and proactive in addressing staff well-being.47 Schwartz rounds, piloted by the King’s Fund from 2009 to 201048 before their widespread use across the NHS,49 are an example of such an approach (see the Point of Care Foundation website for a list of Schwartz round sites in NHS hospitals). Reflective practice groups may be regarded as the middle-ground between one-to-one supervision and organisation-wide Schwartz rounds. Adopted across healthcare organisations in a variety of fields and professions, there are many models for running reflective practice groups,50–53 including but not limited to Balint groups,20 which emphasise the importance of doctor–patient relationships as a therapeutic tool.54 Research into the benefits of reflective practice groups has found attendees reported personal and professional development, improved clinical practice and, in turn, improved patient health outcomes, increased satisfaction and longevity within the workplace—all in the context of improved emotional well-being.55–58

We believe that it has taken some time for principles for action to be formed and implemented across the NHS; the last national audit indicated that although 65% of NHS organisations had a plan in place to support the health and well-being of staff, only around half had operational policies to support mental well-being.42 Most recently, government recommendations for organisations have been developed to tackle staff burnout in health and care sectors.59

Working at a collective level to bolster individual well-being fits with a number of psychological theories including compassion focused therapy.60 Research suggests that the imbalance of focusing attention on tasks and targets rather than shared values and purpose creates challenges for both individuals and the organisation in the form of breakdown in compassion.61 The specific well-being needs of pharmacists, in this context, is an area that is under-researched.62 The ICU environment is associated with increased risk for staff burnout, as defined by experience of emotional exhaustion, depersonalisation, and personal accomplishment63 when the NHS is operating under usual circumstances.

A myriad of factors contributes to this picture, including intensity and type of workload, patient complexity, gender, age group, profession, and the domain of burnout explored.64 Relatively recently published research has found that the risk of burnout, especially in relation to ‘personal accomplishment’, is higher among ICU pharmacists compared with doctors, nursing staff and allied health professionals working in the same environment.64 65 We would echo the conclusions drawn by Vincent et al,64 who say: ‘we strongly support the call to action…(and) believe data such as ours should encourage reflection and empathy at a personal and organisational level, alongside a culture of shared responsibility for all staff throughout their careers’ (page 368), and suggest the pharmacy profession considers these emerging findings for pharmacists working in ICUs and whether this reflects a trend within the profession more generally. There is an opportunity in future to compare the UK situation with international well-being challenges in the ICU, which have been described,65 however this was out of scope for this pilot.

Limitations

This service evaluation was undertaken within a small, self-selected sample of participants, in one organisation which was particularly affected in the earliest stages of the UK’s first wave of the COVID-19 pandemic. Use of a brief, non-standardised self-report survey, completed retrospectively, represent methodological weaknesses that reflect the real-world nature of this research, which was carried out in a novel and still-evolving situation. Questions were phrased in as neutral a way as possible to reduce bias, but this was difficult to eliminate due to the nature of the questions. A strength of the research was the author NF being blinded to the facilitation of the intervention and able to analyse and interpret the qualitative data without bias.

While the weaknesses listed above may have an impact on the generalisability of results, the brevity, simple structure and limit to the formal training completed around reflective practice by the facilitator before undertaking the work, suggest that there is potential in this respect. A repeat of this intervention using a larger sample would provide the opportunity for further qualitative analysis, with themes that may be more representative of the pharmacy profession.

Recommendations

The service evaluation has highlighted the importance of well-being support for pharmacists. We recommend:

  1. The provision of well-being support for pharmacy staff managing complex, rapidly changing and emotionally demanding roles, such as those experienced within the ICU environment

  2. Governance for this work being established with support from, for example, local clinical psychology leads working with departments of organisational development and/or occupational health

  3. Research to be undertaken to explore the value of well-being support for pharmacists in other roles, outside of the context of a pandemic.

Conclusions

This service evaluation has highlighted key themes for pharmacists working in an ICU environment during the pandemic. Provision of opportunities for staff to reflect safely on their personal and professional experiences and to connect with their colleagues in doing so should be regarded as a primary responsibility for organisations, not reserved for times of crisis but as a standard way of working to benefit individual staff, teams, departments, the wider system and, in turn, the populations we serve.

Key messages

What is already known on this topic

  • The COVID-19 pandemic highlighted significant gaps in well-being support for intensive care unit pharmacists in the UK, who were exposed to mental, physical and emotional challenges at this time.

What this study adds

  • This study suggests that group reflective practice sessions supported practitioner well-being. Participants identified that professional and personal ‘permission’, an emotionally secure space, trusting and supportive relationships with colleagues, and methods of managing emotion were needed to attend to their own well-being.

How this study might affect research, practice and/or policy

  • The findings demonstrate heterogeneity in the experience of distress and highlight the need for organisation-led and profession-led pharmacy support as well as opportunities for staff to connect safely with colleagues during such crises.

Ethics statements

Patient consent for publication

Ethics approval

No ethical approval sought as this is a service evaluation. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We thank Dr William Pearson and Dr Saba Haq for their useful suggestions.

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

  • EAHP Statement 6: Education and Research.

  • Twitter @NinaLBarnett

  • Contributors NB and BJ conceived the presented idea. NB carried out the session and the evaluation of survey was completed by BJ. The analysis was completed by NF and SB. All authors discussed the results and contributed to the final manuscript. NB is responsible for the overall content as guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • 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.

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