Becky T

An original article that explores the significance of both staff physical safety in the workplace as well as their psychological safety and wellbeing. In particular, I highlight the impact the COVID-19 pandemic has had on both these areas, and discuss the importance of ensuring all aspects of staff safety. All healthcare workers, from nurses to pharmacists, housekeepers to consultants, should be kept safe as they carry out their essential duties in caring for others. Not only is their physical safety important, but their psychological wellbeing is paramount too. Healthcare workers should be kept safe from all forms of physical occupational hazard, including infectious agents, chemical hazards, workplace violence and ergonomic problems.[1] Specific measures have been put in place to protect the occupational health and safety of health workers, and there are consequential duties, rights and responsibilities for healthcare organisations to uphold.[2] However, just as significant is the psychological safety and wellbeing of staff, as this can have far reaching implications at both a personal and work level. Over-stretched staff can experience fatigue, anxiety, depression and, ultimately, burnout, which is a state of emotional, physical and mental exhaustion caused by excessive and prolonged stress.[3] Presently and perhaps most prevalent is the damaging toll, both physically and psychologically, that the COVID-19 outbreak is having on healthcare workers. As staff have been at the frontline of the pandemic, they have been exposed to multiple different occupational hazards and put at risk. These include exposure to SARS-CoV-2 and other pathogens, violence, harassment, stigma, discrimination, unimaginably heavy workloads and prolonged use of PPE.[2] The International Council of Nurses (ICN) estimated in June that at least 450,000 healthcare workers had been infected with COVID-19.[4] It is therefore clearly important that healthcare institutions provide safe work environments for staff to perform their essential duties.[4] Much focus has been placed on vaccinations, enhanced safety protocols and PPE to protect the physical health of clinicians and staff.[5] The scale of the COVID pandemic has caused mass psychological trauma among the world’s nurses. Moreover, difficulty in providing end-of-life support to patients and their families because of visiting restrictions has been a specific stressor for all staff.[7] Under these trying conditions, healthcare workers are likely to experience anxiety, depression, trauma, burnout and other mental health issues.[5] Reports from the US show that 93% of healthcare workers were experiencing stress at the height of the pandemic, with 76% reporting exhaustion and burnout.[6] A UK study reported that nearly half of ICU staff in England had symptoms of PTSD, severe depression, or anxiety.[7] For physicians, burnout was linked to a four-fold increase in suicidal thoughts.[5] Healthcare organisations ought to recognise the impact that emotional distress has on both patient safety and staff retention during and after the pandemic.[5] There is strong evidence that poor mental health is associated with functional impairment which increases the risk of patient safety incidents.[7] Therefore, equally as important as physical protection are resources to protect staff mental wellbeing. Action steps taken by an organisation before, during and after a crisis will reduce psychosocial trauma and increase the likelihood that staff will cope.[8] For example, hospitals could appoint a Chief Wellness Officer (CWO) and establish a professional wellbeing programme for their staff. It is critical for hospitals and health systems to address burnout from a system-wide level to better care for their staff and to become resilient organisations.[5] Healthcare workers who feel well-supported are less likely to leave their job or reduce their hours worked.[7] Research has highlighted the vital importance of fostering a supportive workplace culture, and the need to provide universal access to high quality wellbeing support and occupational health services.[7] Furthermore, a study has shown that people who engaged with receptive arts activities (such as drawing or painting) on a frequent basis had a 31% lower risk of dying,[9] which highlights the significance of fostering a work-life balance that actively supports mental and physical health. The safety of staff in the workplace is crucial, as is their wellbeing. The COVID-19 crisis has had a destructive impact on staff mental health, as shown in multiple studies worldwide, which cannot be overlooked. The massive elective backlog caused by the focus on COVID means that there is unlikely to be an easing of the strain on healthcare professionals for months if not years to come. It is therefore critical that both the physical and psychological safety of healthcare workers is supported and upheld by healthcare organisations in order to maintain a productive workforce who are better able to serve their patients. Becky Tatum Further reading Why is staff safety a patient safety issue? "I know this is burnout. I didn’t want it to be. But it is." Rethinking doctors’ mental health and the impact on patient safety: A blog by Ehi Iden Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital Understanding moral injury: a short film (HEE and NHSE&I) Hidden Wounds References ‘Health Care Worker Safety Checklists: Protecting Those Who Serve’, Joint Commission International, 2019. [online] Available at: https://store.jointcommissioninternational.org/health-care-worker-safety-checklists-protecting-those-who-serve/?_ga=2.32377150.1488641257.1624913835-465240.1624122412 ‘COVID-19: Occupational health and safety for health workers’, World Health Organisation, 2021. [online] Available at: https://www.who.int/publications/i/item/WHO-2019-nCoV-HCW_advice-2021.1 ‘Burnout Prevention and Treatment’, HelpGuide, 2021. [online] Available at: https://www.helpguide.org/articles/stress/burnout-prevention-and-recovery.htm# Blasi, A., Nunner, K. ‘Ethical principles in health care prove critical to protecting health care workers in pandemic’, Medical Economics, 2020. [online] Available at: https://www.medicaleconomics.com/view/ethical-principles-health-care-prove-critical-protecting-health-care-workers-pandemic ‘WELL-BEING PLAYBOOK 2.0. A COVID-19 Resource for Hospital and Health System Leaders’, American Hospital Association, 2021. [online] Available at: https://www.ihf-fih.org/wordpress/wp-content/uploads/2021/02/caring-for-health-care-workers-covid-19.pdf ‘The COVID-19 Effect: World’s nurses facing mass trauma, an immediate danger to the profession and future of our health systems’, International Council of Nurses, 2021. [online] Available at: https://www.icn.ch/news/covid-19-effect-worlds-nurses-facing-mass-trauma-immediate-danger-profession-and-future-our Mahase, E. ‘Covid-19: Many ICU staff in England report symptoms of PTSD, severe depression, or anxiety, study reports’, BMJ, 2021; 372. [online] Available at: https://www.bmj.com/content/372/bmj.n108 ‘Creating a resilient organization’, American Medical Association, 2020. [online] Available at: https://www.ihf-fih.org/wordpress/wp-content/uploads/2021/02/caring-for-health-care-workers-covid-19.pdf Fancourt, D. ‘The art of life and death: 14 year follow-up analyses of associations between arts engagement and mortality in the English Longitudinal Study of Ageing’, BMJ, 2019; 367. [online] Available at: https://www.bmj.com/content/367/bmj.l6377

In this opinion piece, Becky Tatum discusses how genetic profiling of patient's tumours can lead to more personalised cancer therapy/treatment options with better outcomes. The risks of targeting the wrong cancer Cancer patients often have to undergo rigorous, exhausting treatments and drug regimes, without achieving the improvements or remission that they seek. This is because certain therapies only work on a particular subset of cancers, based on the specific genetic mutations that the cells contain – if the cancer does not contain such mutations, the drug may be pointless. Moreover, patients who lack the mutation targeted by a drug will not only fail to benefit, but can actually be harmed by inappropriate targeted therapies.[1] Therefore, it is essential that cancer treatments are tailored to each patient’s cancer, to save not only NHS money, but personal suffering too. Biobanks and genetic profiling In the UK (and worldwide), there are many tissue biobanks that contain tumour samples for research purposes, such as the Manchester Cancer Research Centre Biobank which brings together organised tissue sample collection across four NHS Trusts under one centralised framework.[2] Biobanks provide an essential service to scientists seeking to perform research on tumour samples to discover new genetic variants or ‘biomarkers’ that could serve as targets for new cancer therapies. In 2013, Genomics England was established to deliver the 100,000 Genomes Project, which aimed to sequence 100,000 whole genomes from NHS patients with rare diseases and common cancers.[3] Tumour data from this project has been used for pan-cancer genome analysis, which looks at the complex patterns of genetic changes specific to different tumour types. In cancer, tumours accumulate genetic mutations as the cancerous cells divide, grow and, in some instances, spread to other parts of the body (metastasise). The resulting tumour cells, although all derived from the patient’s own body cells, may have a very different genetic profile to the parent cells that they originated from. Indeed, as a result of the random process of mutation, the cells of the same cancer could all be different, something called ‘tumour heterogeneity’. A study by Jones et al. in 2015 strongly suggests that cancer tumour genomes should be compared to genomes from noncancerous tissue from the patient so doctors can be sure any mutations found are unique to the cancer. Moreover, when sequenced, not only do the cells in a tumour have multiple genetic changes compared to the patient’s normal body tissue, but tumours of different organ or tissue types also differ genetically from one another – each has its own genetic ‘fingerprint’ and unique pattern of biomarkers. Cancer of the breast, for instance, will have a specific suite of genetic mutations, such as in the well-known BRCA1 and BRCA2 genes, whilst there are different mutations that are characteristic of bowel cancer, such as in the APC gene. Identifying the primary cancer Significantly, as each tumour type has its own genetic profile, it is now possible to tell whether a tumour in a particular part of the body is a primary cancer of that tissue/organ or whether it has metastatised from elsewhere. This builds on traditional oncological investigative procedures. For instance, in 2010 a woman with primary colonic adenocarcinoma discovered a mass in her breast, which upon having a biopsy did not appear colonic in origin (and colon metastases are extremely rare), but after immunohistochemical stains it was eventually revealed that the breast tumour was indeed a colon cancer.[4] Genetic sequencing of the tumour would likely have yielded a much prompter accurate diagnosis. This knowledge of what type of cancer the tumour really is means that drugs to combat it can be prescribed more accurately – and could give a more positive treatment outcome – which would not have been known unless the tumour DNA had been sequenced. Therefore, genetic profiling of a patient’s tumour is extremely important to ensure they receive the correct treatment. Precision medicine and the impact on the patient This all forms the basis of what is known as precision medicine. Precision medicine is ‘an approach to medical care in which disease prevention, diagnosis and treatment are tailored to the genes, proteins and other substances in the patient’s body’.[5] The concept of precision medicine isn’t new, but recent technological advances have meant that this area of research has progressed tremendously in the last decade. Using next generation genetic sequencing technologies, researchers have discovered that two people with the same type of cancer may not have the same mutations, which will affect how successful the cancer treatment will be. As researchers learn more about the DNA changes that drive cancer, they are better able to design promising treatments – usually small-molecule drugs or monoclonal antibodies – that target these genetic regions and proteins. Intermountain Healthcare in the US has been using the power of new genomic technology to conduct research to advance precision medicine, such as looking at the role of tumour heterogeneity and genetic evolution in cancer.[6] At present, genomic analysis isn’t routinely carried out on all cancer tumours in the UK, but as the technology becomes more available and less expensive, it is likely that it will be employed more by clinicians. Promisingly, studies have shown that precision medicine significantly improves survival for patients with advanced cancer when compared to control patients who received conventional chemotherapy, without the increasing associated costs.[7] From a patient’s perspective, it is not hard to see how precision cancer medicine will be of huge benefit. Tumour genetic profiling tells you the drugs the patient is most likely to be responsive to out of multiple possible treatments. Precision medicine saves the sufferer unnecessary pain, time, emotional energy and false hopes. For patients with advanced or metastatic cancer, which can be extremely debilitating, the genomics-based approach appears to be a more viable, and perhaps superior, option compared to standard investigations and treatments. It is, however, important to consider any potential risks to the patient of targeted therapies that are based on genetic profiling. Since the patient’s tumour is genetically sequenced to find targets for treatment, there is a slight risk to the privacy of personal information – genetic information from the patient’s health record may be obtained by people outside of the medical team, such as insurance companies, so it is very important that laws are in place to protect such data from potentially being misused. Final thoughts Precision medicine is ultimately about matching the right drugs to the right patients. Genetic profiling of tumours reveals targeted therapy options that are most likely to be effective against a patient’s specific cancer. All cancers are genetically unique as a result of the mutations they accumulate. Whether genetic profiling is used to determine the true origin of a tumour (perhaps a primary cancer that has metastasised to a completely different organ) or to reveal how one person’s breast cancer (for instance) is different to next persons, this technique allows for much more personalised treatment options than are conventional. As precision medicine is geared to the uniqueness of a patient’s own DNA profile, clinicians can create more promising treatments matched to each individual than ever before, offering hope to people in their darkest hours. Becky Tatum References: 1. Gagan, J., Van Allen, E.M. ‘Next-generation sequencing to guide cancer therapy’. Genome Medicine, 2015; 7(80). https://doi.org/10.1186/s13073-015-0203-x 2. Manchester Cancer Research Centre. (updated 2021) ‘About the MCRC Biobank’. [online] Available at: https://www.mcrc.manchester.ac.uk/research/mcrc-biobank/about-the-mcrc-biobank/ 3. Genomics England. (updated 2021) ‘About Genomics England’. [online] Available at: https://www.genomicsengland.co.uk/about-genomics-england/ 4. Shackelford, R. et al. ‘Primary Colorectal Adenocarcinoma Metastatic to the Breast: Case Report and Review of Nineteen Cases’. Case Reports in Medicine, 2011(738413). https://doi.org/10.1155/2011/738413 5. National Cancer Institute. (updated 2021) ‘Biomarker testing for cancer treatment’. [online] Available at: https://www.cancer.gov/about-cancer 6. Intermountain Healthcare. (updated 2021) ‘Precision Genomics’. [online] Available at: https://intermountainhealthcare.org/services/genomics/ 7. Nadauld, L. et al. ‘Precision medicine to improve survival without increasing costs in advanced cancer patients’. Journal of Clinical Oncology, 2015; 33(15).

An article outlining the significance of needlestick injuries - their risks to healthcare workers, their cost, and the importance of prevention. Needlestick injuries account for 17% of accidents to NHS staff and are the second most common cause of injury, behind moving and handling (nhsemployers.org). The major risk of needlestick injuries is that they can transmit infectious diseases to healthcare workers, especially blood-borne viruses. Many occupational exposure incidents could have been avoided by adopting precautions and by disposing of clinical waste appropriately (nhsemployers.org). Needlestick injuries are wounds caused by needles that accidentally puncture the skin (ccohs.ca). When penetrating the skin, this is called a percutaneous injury, whilst if blood or other body fluid splashes into the eyes, nose, mouth or onto broken skin, the exposure is said to be mucocutaneous (nhsemployers.org). Needlestick injuries can occur at any stage when people use, disassemble or dispose of needles. Causes of needlestick injuries include non-compliance with standard infection control precautions, inadequate disposal of clinical waste, overfull sharps bins, and not using Personal Protective Equipment (resolution.nhs). When needlestick injuries occur in a workplace setting, this is called occupational exposure. If the needle or sharp instrument is contaminated with blood or other body fluid, there is the potential for transmission of infection (nhsemployers.org), which is why needlestick injuries are so dangerous. The major blood-borne pathogens, or blood-borne viruses (BBVs) of concern associated with needlestick injury are hepatitis B, hepatitis C & human immunodeficiency virus (HIV) (nhsemployers.org). However, there are more than 20 diseases that can be transmitted, either transiently or persistently, such as Epstein-Barr virus and malarial parasites. BBVs are carried by some people in their blood and have the potential to cause severe disease (whilst causing few or no symptoms in others); notably, they can spread to others regardless of whether the carrier of the virus is or isn’t symptomatic. BBVs can also be found in bodily fluids other than blood, for example, semen, vaginal secretions and breast milk (hse.gov.uk). Even small amounts of infectious fluid can spread certain diseases effectively (ccohs.ca). Employers have a legal requirement to take steps to prevent healthcare staff being exposed to infectious agents from sharps injuries (resolution.nhs). The Health and Safety (Sharp Instruments in Healthcare) Regulations of 2013 state that all employers are required under existing health and safety law to ensure that the risks of sharps injuries from needles are adequately assessed, and that appropriate preventative and control measures are put in place (hse.gov.uk), such as correct disposal of used sharps and effective workforce training. Needlestick injuries generate significant direct and indirect costs. Between 2012 and 2017, successful claims cost the NHS over £4 million (resolution.nhs). It has been shown that economic efforts directed at preventing occupational exposures and infections, including the provision of safety-engineered devices, may be offset by the savings from a lower incidence of needlestick injuries (Mannocci, 2016). Such devices include needle-free connectors that provide injection ports which can be accessed without needles. For instance, in Belgium, the investment and use of safety-engineered sharp devices has greatly reduced the incidence of needlestick injuries and the costs associated with their management (Hanmore, 2013). Needlestick injuries are a well-known risk in the health and social care sector. Because of their potential for disease transmission, such injuries can cause worry and stress to the many thousands who receive them. Most needlestick injuries can, however, be prevented, and there are legal requirements on employers to take necessary steps to prevent healthcare staff being exposed to the transmission of diseases via this safety issue. References Canadian Centre for Occupational Health and Safety (2021). ‘Needlestick and Sharps Injuries’. [online] Available at: https://www.ccohs.ca/oshanswers/diseases/needlestick_injuries.html Hanmore, E. (2013). ‘Economic benefits of safety-engineered sharp devices in Belgium - a budget impact model’. BMC Health Serv Res. [online] Available at: https://pubmed.ncbi.nlm.nih.gov/24274747 Health and Safety Executive (2001). ‘Blood-borne viruses in the workplace’. [online] Available at: https://www.hse.gov.uk/pubns/indg342.pdf Health and Safety Executive (2013). ‘Health and Safety (Sharp Instruments in Healthcare) Regulations 2013’. [online] Available at: https://www.hse.gov.uk/pubns/hsis7.htm Health and Safety Executive (2020). ‘Sharps injuries’. [online] Available at: https://www.hse.gov.uk/healthservices/needlesticks/index.htm Mannocci, A. et al. (2016). ‘How Much do Needlestick Injuries Cost? A Systematic Review of the Economic Evaluations of Needlestick and Sharps Injuries Among Healthcare Personnel’. Infection Control and Hospital Epidemiology, 37(6). [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4890345 NHS Employers (2011). ‘Needlestick injury’. [online] Available at: https://www.nhsemployers.org/-/media/Employers/Documents/Retain-and-improve/Health-and-wellbeing/Needlestick-Injury-22-02-2011.pdf?la=en&hash=44A54B023D6C14CE21C749A226435581BD8F4FE8 NHS Resolution (2017). ‘Did you know? Preventing needlestick injury’. [online] Available at: https://resolution.nhs.uk/wp-content/uploads/2017/05/NHS-Resolution-Preventing-needlestick-injuries-leaflet-final.pdf

In this blog, patient Becky Tatum reflects on two articles in Forbes magazine describing how technology is enabling patient's with multiple chronic conditions who may have been discharged from hospital, to now be provided with aftercare in their own home. Becky looks at the pros and cons of receiving hospital treatment at home from a patient's perspective.   Hospital-level care at home, in the form of remote monitoring and daily visits from medical professionals, is being touted as the potential future of healthcare, saving money and freeing up hospital beds. But as well as the financial considerations, it is important to reflect upon how this approach would feel to you as a potential patient in receipt of this novel treatment approach. As a patient, the upsides to being treated in your home instead of in hospital are obvious. It saves time and money to not have to travel to the hospital regularly for treatment. You are in the familiar setting and comfort of your own home, which is likely to leave you happier and more relaxed. It’s comforting and gives you peace of mind knowing that family members are nearby. Moreover, you are not restricted to seeing loved ones at set visiting times, which (as we know too well) during the height of the COVID-19 pandemic were (and still are) extremely limited, or in many cases not allowed at all. Also, it would be less noisy at home compared to being in hospital, with none of the unwelcome sounds from other patients, the nursing station, etc. Another upside is that you don’t have to go to an area where you would mix with others who may have communicable infections, which is always a real risk for immunocompromised patients. From the point of view of the care you receive, the attention of the medical staff is focused fully on you with no distractions, rather than having to see many patients in quick succession, so care is likely to be of higher quality and more personalised. But, the downsides to such a treatment approach are aplenty. Firstly, being treated in your home is an invasion of personal privacy and removes the boundaried distinction between home and hospital – some patients might want to keep the two domains very separate. Secondly feelings of uncertainty and unsafety may result from not being in a purpose-built medical environment with staff at your call 24/7, promoting worries such as, ‘will medical concerns be picked up soon enough?’ and ‘will staff turn up when they are supposed to?’, to name but two. There could potentially be a delay in medical intervention in the time it takes for staff to attend the home once an alarm has been raised, especially in rural areas or if weather conditions are bad; this could be dangerous if the patient goes into crisis and rather than call for an ambulance they wait for their community-based carer. There may also be the tendency for more mobile patients to over-do things and be too active in their home environment; simple things like letting the dog out or just making a cup of tea might be too much physical effort compared to the limited self-sustaining activity necessary for people in a hospital bed. There are practical and social considerations, too. If living independently or in a household where family members aren’t always available, the lack of regular physical support to wash, prepare food, etc, may be an issue – so for some people, medical care would need to be augmented with social care. Even the act of letting staff into the home may be problematic if you have reduced mobility and there is no-one else at home. And, with knowing that (essentially) strangers are continually entering your home, you may feel the need to keep your house tidy at all times, too, which adds extra pressure. It would also be very disruptive for other family members that are present to have staff constantly arrive and depart, invading their personal or work space as well as the patient’s. Then there is the impact on the environment from the various medical professionals driving around to patients’ homes multiple times each day, something the eco-conscious cannot overlook. Overall, there are pros and cons in being treated in your own home instead of in hospital. Receiving high-acuity care and monitoring in the home environment is promoted by hospitals and insurers as the potential way forward for hospital treatment. But whether this is the future of hospital care or not, crucially needs to take into account the views of the patient, which will always be unique. Forbes articles Moving More Medical And Long-Term Care To Seniors’ Homes Home Health Care Is A Bright Light During Covid-19 With An Even Brighter Future