Table 1

Key findings, tensions and exemplar CMOcs

Key finding	Tension	CMO	Context–mechanism–outcome configuration
It is difficult to promote staff psychological wellness where there is a blame culture.	A lack of collective accountability vs a team/system-based approach.	1	Front-line staff are most directly linkable to outcomes and errors (C); a focus on performance measurement and accountability of individual staff can preclude acceptance of system-wide accountability (M-resource), leading to staff practising defensively to avoid blame (M-response), reducing job satisfaction and increasing risk of secondary trauma (O).
	Needing to raise concerns vs fitness-to-practise processes felt as being oppressive.	5	When medical errors occur in an organisation where staff do not feel psychologically safe (C), investigation of errors (M-resource) may make staff feel unheard or blamed, and they may fear public exposure and reputational damage and not able to speak up, and instead feel guilt and shame (M-response), leading to silencing, frustration and secondary trauma (O).
	Encouraging staff to speak up vs the ‘deaf effect’ response from managers and hearers.	6	When it is not psychologically safe to speak up about mistakes or where senior leaders do not listen to staff concerns (C), when encouraged to speak up and raise concerns (M-resource), staff will fear the consequences or feel there is no point as no change will result (M-response), leading to decreased workplace satisfaction, reduced quality of patient care and increased secondary trauma (O).
‘Serve and sacrifice’: the needs of the system often over-ride staff well-being at work.	A culture in which staff prioritise institutional needs vs a culture that promotes self-care.	8	When high workloads are normalised in professions that are exhorted to put patients first (C) and if staff are told to give 100% to serve patients without providing support strategies (M-negative resource), this reinforces compliance to institutional needs to the detriment of staff needs (M-response), leading to guilt and increased stress, burnout and intention to leave/attrition (O).
	Supporting staff in the context of staff shortages vs the need to fill ‘extra’ vacant shifts.	9	Managers feel pressure to ensure safe staffing levels despite staff shortages (C); if managers communicate this pressure to staff ‘begging’ them to work extra shifts (M-negative resource), staff can feel coerced and/or guilty when they say no (M-response), preventing non-work time from being regenerative, leading to increased job dissatisfaction, presenteeism and burnout (O).
	The lived reality of staff shortages vs the wish to deliver high-quality care.	10	Staff shortages mean there is less time to care for each patient (C) and staff cannot provide their preferred quality of care (M-negative resource), leaving them feeling frustrated, angry and guilty at care left undone (M-response), leading to moral distress, burnout and intention to leave/attrition (O).
There are unintended personal costs of upholding and implementing values at work.	The reality of healthcare delivery vs the taught theory and values.	13	If newly qualified staff have developed idealised visions of work (C), then when pressures caused by systemic factors mean their practice may not align with such ideals (M-negative resource), they may feel moral distress (M-response), causing reduced job satisfaction, burnout and attrition (O).
	The benefits of staff empathy to patients vs the harms of such empathy to themselves.	14	Staff are recruited based on values, including compassion (C); when they are genuinely empathic (M-resource), they are better able to understand patients’ pain/suffering (M-response1), leading to better patient care and increased job satisfaction (O1), but empathising with patient suffering may cause staff distress (M-response2), leading to burnout, secondary trauma and attrition (O2).
	The emotional labour required for health work vs protecting staff’s psychological ill health.	16	Healthcare staff may be exposed to injuries or suffering that evokes natural emotions such as repulsion, fear or distress (C), but have to repress responses to protect patients (M-resource), which can lead to emotional distress in staff (M-response), causing suppressed emotions to come out in other dysfunctional ways, impacting job satisfaction, performance and psychological health (O).
Interventions are fragmented, individual-focused and insufficiently recognise cumulative chronic stress.	A focus on individuals vs a focus on systemic issues.	18	When there is normalisation of unpaid overtime and an absence of a systemic focus on well-being (C), if leaders encourage staff to prioritise self-care (M-resource) staff may feel their leaders are out of touch with reality (M-response), leading to reduced job satisfaction, work engagement and morale (O).
	A focus on acute trauma episodes vs recognising and supporting chronic cumulative stressors.	20	Constant low-grade trauma exposure to patient suffering, resource scarcity and staff shortages may not be visible (C), meaning that managers may not recognise the cumulative build-up of stress (M-negative resource) and may thereby judge staff competency unfairly (M-response), causing increased stress, risk of secondary trauma and intention to leave/attrition in staff (O).
It is challenging to design, identify and implement interventions.	Making staff wellness interventions mandatory vs making them voluntary.	22	When prioritising staff well-being (C), attendance at a wellness intervention may be mandated when some staff are not receptive to it (M-resource), leading to staff feeling that the approach is a tick box and lacking authenticity, and then feel resentful, anxious, exposed or stigmatised at sharing emotions (M-response), causing staff work disengagement and feeling less secure/likely to speak up (O).
	Spaces to debrief with leaders vs peer-led spaces for debriefing.	25	Healthcare staff may be exposed to chronic and acute trauma (C); if mentors offer kindness and spaces to be heard (M-resource), staff feel their experiences are important and recognised (M-response), and are helped to recover, continue with work and protected from further harm (O).
	The need to offer support vs providing interventions too soon, too reactive and/or at a single timepoint.	26	If staff’s basic physiological and safety needs are not met (C), then when they are offered other support/interventions such as end-of-shift debriefing (M-resource) they may feel frustrated and upset due to the lack of recognition of their other essential needs, and fatigue and exhaustion due to intense working shifts preventing attendance (M-response), causing low uptake /engagement and exacerbation of distress/trauma response (O).

see online supplemental appendix 4 for all CMOcs.
CMOcs, context–mechanism–outcome configurations.