‘You want to care for children but you spend all day hurting them’

"You go into paediatrics because you want to care for children and then you spend all day hurting them" – injecting them and subjecting them to other procedures, says consultant psychologist Barbara Wren.

That, she acknowledges, “is a mad way of describing it but psychologically that is what you’re doing”. The chances are you will be inflicting pain on parents too, telling them what they don’t want to hear.

Delivering the recent annual Children in Hospital Ireland lecture on building and maintaining resilience when working with children in hospital, Wren showed a slide of a beautiful baby, the sort that elicits a spontaneous "ahh". The longing for children is a basic desire and instinct in most of us, she suggests, but people going into paediatrics may have additional motivations to care for them, perhaps having experienced illness as a child, either personally or a sibling's.

But that picture of loveliness was quickly followed by a close-up photo of a very distressed child’s face.

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"There is nothing worse than seeing a child in pain," says Wren in an interview with The Irish Times. The innate desire of people going to work in children's hospitals is one thing – but what they get is something different.

“Some of these children won’t live, most of these children are suffering and some of your dreams might be shattered too,” she says.

If organisations aren't supporting staff enough, that's exactly where the risk of burnout is

Such psychological complexities can take a toll on healthcare staff who work with children, while parents at the bedside face their own challenges. Their identity as the most important person in their child’s life is threatened because without the hospital their child can’t get well.

“You are having to relinquish power – consciously or unconsciously. A lot of other people are more powerful than you – and they all have their needs too.”

There is this "whole whirlpool of feeling", she explains, which is why she called her lecture Keeping the Child in Mind.

“Feeling is good as long as it is managed; everybody has to keep the child in mind from a different position.” For example, a consultant has to be logical, stark and robust in deciding on a particular kind of chemotherapy, while the nurse has to stay close to a child who is distressed and encourage them to keep going.

Space to think

She has seen where things have gone wrong in paediatric settings often “because there has not been enough space to think and feel, and people have got out of position. For example, people are over-treating children because they can’t bear to tell parents the truth. Parents are bullying doctors because it is so tough.”

Wren, who grew up in Ireland and studied in Trinity College, Dublin, is author of the book True Tales of Organisational Life. It draws on her experience of introducing "Schwartz Rounds" in the UK, designed to give healthcare staff that vital safe space to think and feel.

Devised in the US, the rounds involve a multidisciplinary panel of staff sharing their stories in front of other colleagues. They may be giving different perspectives on one case or talking on a chosen theme, such as “a patient I’ll never forget”.

Discussion at these sessions is then opened to the audience and all participants are asked to observe confidentiality about what is shared.

“The way I always manage it in the rounds that I have facilitated is to say that we do want you to go away and talk about these themes and issues but not in a way that will identify anybody,” says Wren.

Schwartz Rounds started in Ireland on a pilot basis three years ago, in University Hospital Galway and the Blackrock Hospice in Dublin. They are now operating in 14 sites, according to the Health Service Executive, including the National Children's Hospital in Tallaght and Temple Street Children's University Hospital. The HSE's Quality Improvement Division is working with the Point of Care Foundation to extend the rounds to 30 sites within two years.

While some professions are better than others at providing opportunities to reflect, the open, cross-disciplinary nature of this work has proved particularly valuable.

As a psychologist available to NHS staff at the Royal Free Hospital in London, before she started the rounds there in 2009, Wren was struck how individuals would tell her behind closed doors how they were failing in their job, believing they were the only ones who felt that way.

“We tend to have a very linear view and a lot of shame, and we think we go to a psychologist when there is a crisis.” She reminds staff that frontline healthcare is tough work for everybody, regardless of their role.

“One of the most powerful rounds I did was a porter bringing a baby’s body to the mortuary. Nobody thinks about that – they don’t get paid much, they don’t get trained in the same way. Or, for example, secretaries who are typing letters that are stories of distress, really. So, the rounds are for everyone.”

The demanding nature of healthcare jobs is exacerbated in both the NHS and the HSE by overcrowding, staff shortages, longer waiting lists and other resource issues. Yet while stories of stressed staff and “compassion fatigue” predominate, it is also really meaningful work, Wren points out.

“The way people stay motivated is staying in touch with the meaning of the work, and if organisations aren’t supporting them enough, that’s exactly where the risk of burnout is.”

Predictable risks

In an over-pressurised system “you get risk to patients, as well as staff burnout, because the only way to survive is to shut down emotionally. It is not just that you won’t be kind and compassionate but your communication will probably also be affected because you won’t be listening as well”.

That’s why Wren stresses that supporting staff is not only important for their well-being but also for improved effectiveness. So, it matters hugely to all of us who use, as well as to those who work in, our health system.

There is an abundance of evidence that makes risks to healthcare staff completely predictable, she says, so support programmes need to be integral for effective working – and not just rolled out in a crisis.

A national evaluation of Schwartz Rounds in the UK 2014-2017 reported a drop in psychological distress from 25 per cent to 12.5 per cent for staff who attended them over a two-year period.

Here, preliminary findings of an evaluation study by Trinity College Dublin on the two pilot programmes show that at one centre 85 per cent of participants agreed that they gained insight at Schwartz Rounds that would help them to care for patients and 96 per cent agreed that it would help them work better with their colleagues. The corresponding figures at the second centre were 97 per cent and 95 per cent. At both, nearly all participants intended to keep attending them.

They have been introduced at Temple Street Children's University Hospital within the last year and have been extremely well attended and positively received, says consultant paediatrician Alf Nicholson. They're generally at lunchtime, "everybody goes in and the doors are shut, so people can't come and leave – it's undisturbed time. If there is anything you want to say that has affected you it stays confidential."

Paediatrics is a pressurised environment, he says, with people expecting a perfect outcome every time. And thanks to huge advancements in medicine, there are vastly improved outcomes for children with, say, cystic fibrosis, heart conditions and cancer.

“The expectation in the public is really very high and when something goes wrong, such as an acute infection or a road traffic accident, it is such an unexpected happening it becomes a real catastrophe for everybody.

“There is not just the victim, the family and the community, but the second victim is the medical, nursing and other healthcare professionals who become involved in the case,” he points out. “They feel it as well. They get this huge sense of ‘something horrendous has just happened, how do I handle that and keep going, and what to learn from it’.”

Tough decisions

As RCSI professor of paediatrics, Nicholson is a co-director of the two-year postgraduate training programme for junior doctors specialising in paediatrics.

One of the biggest challenges in postgraduate medical training, he explains, “is that you start dealing with uncertain situations: ‘He has a temperature, it’s probably a viral illness, I think he can go home but what if he came back with meningitis in six hours’ time? What would the parents think and how would I feel?’

“If you think about that for every child you see, you really cannot function on the frontline at all.”

They try to prevent fear paralysing inexperienced doctors’ decision-making through training and consultant back-up. “But even with that it can still be an issue, particularly if something goes wrong.”

There are 42 trainee paediatricians working in hospitals around Ireland who are brought together for regular training days.

“The focus is on, ‘we’re not perfect, the system isn’t perfect, how do we make sure we do the very best we can?’. But it is tough.”

He says the case in the UK of trainee paediatric doctor Hadiza Bawa-Garba, who was convicted of the manslaughter of Jack Adcock, a six-year-old boy with Down syndrome and a heart condition who died of sepsis, has had a huge impact on junior doctors. She received a suspended sentence for her conviction in 2015 and was also suspended for a year from the UK medical register. But last January the High Court in London ruled that she be struck off the register, after an appeal by the General Medical Council.

“It has caused a lot of trauma,” he explains. “She was under a lot of pressure that day, somebody hadn’t turned up and the consultant was in another hospital and there were so many extenuating factors. The ward was very busy.

“It’s a very hot issue among trainees – where does my responsibility start and finish? If things go wrong, am I going to be put out there to be stoned by the community?”

The reality is that even very experienced healthcare staff will make errors.

“If you deal with human factors in human systems, mistakes are an integral part of it and what we need to try to do is to ensure that the system generally ‘soft lands’ any mistakes that happen,” adds Nicholson. “That is the whole purpose of a safer system.”