helping nhs leaders, teams and individuals to recover from

Helping NHS leaders, teams and individuals to recover from the trauma of Covid-19a compassionate approach

ContentsForeword 3

Setting the scene 4

How Covid can be distressing 5 for our staff

Trauma Informed Care 6

Compassionate and Inclusive 7 Leadership

The relevance of the 8 ‘Compassionate Mind Model’ in response to Covid-19

Strategies to prevent a traumatic 9 impact from Covid-19

The process of recovery after 12 Covid-19

Conclusion 13

Appendix 14

Avon and Wiltshire Mental Health Partnership | TICL 2

Foreword None of us has previously experienced anything like Covid-19. Our way of working and indeed our lives have changed so much, demanding that we adapt at a phenomenal pace. Some of these changes are good ones and to be celebrated. However, the events of the last year, combined with the difficulties faced by the NHS prior to this, have left many staff exhausted and working longer hours than ever before.

At AWP we have brought together Trauma-Informed Care and Compassionate Leadership to help guide us in supporting staff through these extraordinary times. We have produced this leaflet to help executive teams lead the NHS to recover from the impact of Covid-19 by thinking critically – and in very practical ways - about the best approaches to support

individuals, teams and leaders. We hope that you find it as useful as we have.

Dominic Hardisty, Chief Executive [email protected]

“Compassionate, continually improving and high quality care

for patients and service users is completely dependent on

compassionate, continually improving and high quality support for staff. This leaflet provides a wonderful

source of guidance for achieving precisely that.”

Professor Michael West CBE, Senior Visiting Fellow,

The King’s Fund


Setting the scene

When people are exposed to situations like Covid that are life-threatening there is the potential for psychological trauma and post-traumatic stress. In addition, some people may have prior experience of trauma as well as circumstances of fear, isolation, and loss similar to those caused by Covid. Covid therefore may itself trigger a trauma, or may bring to the foreground traumatic experiences from people’s pasts. It has also had a disproportionate impact on groups with increased vulnerability to Covid-19, such as Black, Asian and Minority Ethnic (BAME) staff and people with particular, underlying health conditions.

When someone has experienced trauma it can impact on them in a wide range of ways such as finding it hard to trust people, to give away control, or to feel safe in unfamiliar environments or with people they don’t know.

During the first wave of Covid-19 a study found that many health and social care workers met the criteria for anxiety, depression and post-traumatic stress disorder. However, research also tells us we need to balance against this the fact that most people are fundamentally resilient, so will learn to cope with what life throws at them. This requires a style of leadership that is compassionate and inclusive.


Derek works in a community team,

many of his caseload have experienced trauma and are

distressed. He is struggling to support them and he does not have access

to his usual coping methods )e.g. the gym). Derek is likely to be

experiencing compassion fatigue due to the demands on him

exceeding his current capacity to recover.

How Covid can be distressing for our staff

Ellen is the only Doctor

available when two crtically ill patients are being

considered for one ICU bed. She is aware that her decision may

put the life of the other person in jeopardy and this conflicts with her values of treating everyone equally

and to the same standard. This situation is therefore emotionally and morally

distressing.

Sue is a BAME member

of staff working on an inpatient ward with Covid-19 patients. She

believes that she will catch it and that her life is in danger. Sue is at risk of developing

Post-Traumatic Stress Disorder.


This could well imply a change in the way that many of our leaders lead.

Our working environment needs to embody these principles. The first of these is safety, including psychological safety, which is about making the work environment safe for interpersonal risk-taking. With psychological safety representing one of the links to Compassionate Leadership.

This means that we need to adopt Trauma-Informed principles to reduce the possibility of further distress. These are:

Choice

People are given choice and control; they know their rights

and responsibilities

Empowerment

Build skills, create an atmosphere that

allows people to feel validated and affirmed

Collaboration

Including people in the decisions that are made and that power

is shared wherever possible

Cultural Humility

A respectful approach toward individuals of

other cultures that continuously pushes

one to challenge cultural biases

Trustworthiness

Honesty, deliver on agreements, clarity about

tasks, well maintained interpersonal boundaries,

being respectful

Safety

Ensuring that people feel both physically and

psychologically safe

Trauma Informed Care


Compassionate and Inclusive Leadership

Professor Michael West suggests that there are four components to Compassionate Leadership:

Attending

Paying attention to the other person and noticing their

suffering

Empathising

having an empathic response, a felt reaction to the other’s distress

Understanding

What is causing the other’s distress, by

making an appraisal of the cause

Helping

taking thoughtful and appropriate action to help relieve the

other’s suffering

Ensuring these four components are reflected by leaders at all levels of the NHS is vital, particularly at the present time. Leaders who attend, understand, empathise and help have a positive influence on staff wellbeing, patient/service user care and organisational culture. Inclusive leadership ensures equity, valuing diversity and promotes inclusion.

Professor West also notes that compassionate leadership starts with self-compassion. By starting with compassion to ourselves and understanding the key importance of this for our wellbeing, we can better nurture ourselves and support others.


The relevance of the ‘Compassionate Mind Model’ in response to Covid-19The Compassionate Mind Model draws on evolutionary theory, suggesting that there are three main components to our emotion regulation system that ensure our survival: our Threat system, our Drive system and our Soothing system.

Our Threat system focuses on detecting threat and protecting us, so has been key for our survival and is triggered by immediate or imagined danger. Our Drive system motivates us to achieve. Finally, our Soothing system works to slow us down, recognising the importance of balancing our threat and drive systems to know we are safe.

During the pandemic, our Threat system has been activated, making it hard to think clearly and more likely we react with feelings such as anxiety, frustration or anger. Our Drive system has also been activated, motivating us to continually over-work as we strive to make a difference and control what we can. However there is a risk of doing too much, leading to exhaustion. At these times, we should therefore think about activating our and others’ Soothing systems so that we can restore balance, helping others and ourselves.

Soothing System

Feelings: Contented, safe,

protected, cared-for, trust

Drive System

Feelings: Wanting pursuing,

achieving, progressing, focused

Threat System

Feelings: Anxiety, Anger,

Disgust


Strategies to prevent a traumatic impact from Covid-19

When our threat or drive systems are overactive, engaging in our own self-care first (activating the soothing system) can put us in a better position to be compassionate to the patients we support and the staff we work alongside.

This is key as compassion fatigue occurs when the energy it takes to be compassionate is greater than the capacity we have to recover. The most compassionate amongst us may well be those who are most affected. In looking after ourselves first, we are in a much stronger position to help others and ultimately to be a role model for the shift in culture the NHS needs towards one that prioritises the health and wellbeing of our staff.

9Avon and Wiltshire Mental Health Partnership | TICL

Good, Clear, Timely Communication, Information and Training.

• Discuss demands with staff in an open, honest and frank way so they are best prepared.

• Provide training on potentially traumatic situations staff might be exposed to.

• Be flexible in supporting needs & respond to staff on what is & is not helpful or possible.

• Buddy less experienced with more experienced colleagues

• Protect vulnerable staff members and prevent personal / professional isolation.

Fostering Team Spirit and Cohesion

• Create opportunities for staff teams to talk, catch up and support each other.

• Organise opportunities for staff to reflect, think and talk about their experiences at work (for post-incident support this should involve trained facilitators and focus on normalising reactions to traumatic events and mobilise social supports). In AWP we call these Staff Support Debriefs.

• Don’t offer mandatory, stand alone, “Psychological Debriefing” which forces people to talk about distressing experiences and focuses on their feelings during the event.

There are then some very practical actions that we can take to support staff wellbeing at work:

High Quality Psychological and Wellbeing Services for Staff

• Actively monitor staff’s wellbeing and have a low threshold for staff being referred for help with their mental health.

• Only use trained & competent staff to deliver evidence-based psychological interventions

• Help staff to keep well – be a role model: Rest, sleep, food, drink, safety…

• Don’t rush to use psychological interventions too soon– they may interfere with people’s natural coping mechanisms and most people will be resilient.

10Avon and Wiltshire Mental Health Partnership | TICL

Basic needs• Rest, sleep, food, drink,

safety, exercise...

One of the most important determinants of wellbeing at work is our relationships with our immediate managers, reinforcing the need for compassionate leadership. The social support provided by colleagues, friends or family is also key. A key predictor of PTSD, depression and anxiety amongst frontline health and social care workers is if the staff member feels unable to tell their manager they are not coping. Therefore, it is crucial that senior leaders support team managers better to support their staff’s wellbeing.

These actions represent sensible steps for staff wellbeing, many of which will already be in place. However, it is important to continue encouraging staff to utilise further support.

Information and peer support

• Provide people with the information they need and

ensure there are opportunities for staff to support each other The British Psychological Society recommend that

support for staff should be offered in a stepped manner, with research indicating that most staff will be resilient. This should be offered in a culture of compassionate and inclusive leadership.

At times of high stress and demand attending to basic needs such as rest and sleep are the priority. Actively supporting this is a key task for all NHS leaders. For staff who do experience an adverse impact, these layers of support can be provided by the organisation, with specific psychological interventions for mental health needs.

Psychological First Aid/

Staff Support Debriefs• Provide support and practical

help following difficult situations or a crisis

• Offer voluntary, supportive spaces with trained facilitators after traumatic

events to promote normal coping responses and mobilise

peer support

Psychological intervention

• Monitor the wellbeing of staff and assist them to access

treatment if needed and if appropriate at this time


The process of recovery after Covid-19

Much has been written about this already with the Kings Fund and British Psychological Society offering useful insights.

We believe that the framework used in psychological therapy to help people recover from trauma offers a useful structure to plan our response. This involves three phases of Safety and Stability; Remembering; and Reconnecting and the table opposite gives some examples of actions at each stage.

It is crucial that sufficient time is given to recover before we reconnect with our NHS objectives. The pressure of waiting lists, paused projects and new initiatives might well feel comforting as it activates our Drive system, or indeed our Threat system, but it runs the risk of causing staff burnout if we haven’t paid enough attention to restoring ourselves first. This includes those who are ‘helping the helpers’ – our leaders.

Safety and stability

When demands are highest on staff and the focus is on getting through

Remembering

The phase when the peak of demands has passed and staff are moving to a position where they feel less threat

Reconnecting

At this stage people are recovered as best they can and are feeling ready to reconnect with work and life goals

Help people learn ways of coping and mobilise resources to support them

Talking about what has happened, mourning for losses.

Identifying new purpose and meaning, restore or create connections with others

Keep social connections to others

Rest, eat, drink, sleep

Training, peer support

Give people the information they need

Allow people to talk about their experiences if they want to, what has been lost and gained

Reflective practice

Identify moral distress

Monitor for compassion fatigue, mental health needs

After a sufficient period of time, start to reconnect with plans, goals and objectives that have been put on hold

Offer thanks and rewards to staff for what they have done

Build on areas of growth from Covid-19 and learn key lessons.

Ensure access to psychological and other wellbeing support


Conclusion

We would summarise key ‘takeaways’ for Executive Teams in the following way.

• Trauma-Informed Compassionate Leadership is a useful framework to help us cope with and recover from Covid-19.

• Although the most common response for people is resilience, there is also the potential for a traumatic impact on staff who have a vulnerability to Covid-19.

• We should respond by first engaging in our own self-care. We all need to rest and recover. Time will be needed to make sense of what has happened, talk about distressing experiences, mourn for what has been lost and reflect upon what has been learned. This will enable us to build our capacity to show compassion to others.

• We will need to support team leaders so that they in turn can support their teams. We can achieve this by leading in a compassionate and inclusive way.

• If staff are distressed we should support them to access help in a compassionate and caring way that does not trigger further distress or shame. The support they get will need to be Trauma-Informed.

• This process of healing will help NHS organisations to move on and reconnect with their aims, objectives and ambitions.

• The time to start planning the process of recovery is now.

We would suggest that executive teams consider and discuss these points together, then agree what (if anything) they want and need to do to improve their support for individuals, teams and leaders, and how they can share any recommendations or key actions within their organisations.


Created by the Joint Chairs of the AWP Trauma Response Group:

Dr Emma Griffith, Consultant Clinical Psychologist, Head of Therapies for the Specialised Services of AWP; Honorary Lecturer University of Bath; and

Dr Chris Gillmore, Consultant Clinical Psychologist, AWP Lead for Staff Psychological Wellbeing and Trauma-Informed Care, Honorary Lecturer University of Bath

Acknowledgements:

The training on which this leaflet is based was created by the AWP Trauma Response Group, which is a collective of clinicians from across AWP NHS Trust, working to prevent and respond to staff trauma, whom we would like to acknowledge and thank for their contributions.

Thanks also go to Laurainne Copnall, Culture Transformation Team, NHS England and NHS Improvement, Professor Michael West CBE, Senior Visiting Fellow, The King’s Fund, and Dr Jo Billings, Consultant Clinical Psychologist, Associate Clinical Professor, UCL Division of Psychiatry.

February 2021

Appendix


Appendix

Greene, T., Harju-Seppänen, J., Adeniji, M., Steel, C., Grey, N., Brewin, C.R., Bloomfield, M.A., Billings, J. (2021). Predictors and rates of PTSD, depression and anxiety in UK frontline health and social care workers during Covid-19. European Journal of Psychotraumatology. DOI:10.1080/20008198.2021.1882781.

Trauma Group (2020). Coordinating a trauma-informed response to Covid 19 - What, why and how? https://232fe0d6-f8f4-43eb-bc5d-6aa50ee47dc5.filesusr.com/ugd/ 6b474f_2cdef2cbb07241c09656937e76907018.pdf

Office for National Statistics (2020). Child abuse in England and Wales: March 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/bulletins/childabuseinenglandandwales/march2020

Sweeney, A., Clement, S., Filson, B. & Kennedy, A. (2016). Trauma-informed mental health care in the UK: what is it and how can we further its development? Mental Health Review Journal, 21(3), 174-192.

Edmondson, Amy C. The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. Hoboken, NJ: John Wiley & Sons, 2018. West, M., Eckert, R., Collins, B., and Chowla, R.

(2017) Caring to change: How compassionate leadership can stimulate innovation in health care. London: The Kings Fund. Retrieved from: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Caring_to_change_Kings_Fund_May_2017.pdf

DOH and Social Care, updated 1 January 2021. The NHS Constitution for England. https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england accessed 08.02.21

West, M. A. & Chowla, R. (2017). Compassionate leadership for compassionate health care. In Gilbert, P. (ed.). Compassion: Concepts, Research and Applications. (pp. 237-257). London: Routledge.

Dawson, J.F et al.. (2011), Department of Health, London

West, Dawson, Admasachew, & Topakas, 2011

National Improvement and Leadership Development Board. (2015). Developing People – Improving Care. A national framework for action on improvement and leadership development in NHS-funded services. UK. https://improvement.nhs.uk/documents/ 542/Developing_People-Improving_Care-010216.pdf

References:

NHS Improvement and The Kings Fund (2017). Getting Started Phase 1: Discover. Culture and Leadership Programme. https://improvement.nhs.uk/documents/1628/01-NHS101_01_Improvement_Mini_Guide-Getting_started__050417_I.pdf

West and Bailey., 2019 https://www.kingsfund.org.uk/blog/2019/05/five-myths-compassionate-leadership

Gilbert, P. Evolution, Compassion and Happiness. https://www.compassionatemind.co.uk/uploads/files/evolutioncompassion-and-happiness.pdf (downloaded 9.2.21)

Trauma Group (2020). Guidance for planners of the psychosocial response to stress experienced by hospital staff associated with Covid: Early Interventions. https://232fe0d6-f8f4-43eb-bc5d-6aa50ee47dc5.filesusr.com/ugd/6b474f_daca72f1919b4c1eaddb8cfcbb102034.pdf

Hesketh, I. & Cooper, C. (2019). Wellbeing at work: How to design, implement and evaluate an effective strategy. Kogan Page.

British Psychological Society Covid19 Staff Wellbeing Group (2020). The psychological needs of healthcare staff as a result of the Coronavirus pandemic. Leicester: British Psychological Society.

Herman, J. (1992). Trauma and Recovery: The Aftermath of Violence – from Domestic Abuse to Political Terror. New York: Basic Books.

Billings, J., Biggs, C., Chi Fung Ching, B., Gkofa, V., Singleton, D., Bloomfield, M. & Greene, T. (In press). The experiences of mental health professionals supporting frontline health and social care workers during Covid-19: A qualitative study. BJPsych Open.


https://232fe0d6-f8f4-43eb-bc5d-6aa50ee47dc5.filesusr.com/ugd/6b474f_2cdef2cbb07241c09656937e76907018.pdf



https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/bulletins/childabuseinenglandandwales/march2020




https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Caring_to_change_Kings_Fund_May_2017.pdf



https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england




https://improvement.nhs.uk/documents/542/Developing_People-Improving_Care-010216.pdf



https://www.kingsfund.org.uk/blog/2019/05/five-myths-compassionate-leadership



https://www.compassionatemind.co.uk/uploads/files/evolutioncompassion-and-happiness.pdf



https://232fe0d6-f8f4-43eb-bc5d-6aa50ee47dc5.filesusr.com/ugd/6b474f_daca72f1919b4c1eaddb8cfcbb102034.pdf



Avon and Wiltshire Mental Health Partnership NHS TrustBath NHS House,Newbridge Hill,Bath BA1 3QE

Useful Resources:

The Kings Fund – articles on recovery from the Covid-19 pandemic

https://www.kingsfund.org.uk/blog/2021/01/recovery-and-then-renewal-innovation-health-and-care-covid-19

https://features.kingsfund.org.uk/2021/02/ covid-19-recovery-resilience-health-care/

Our NHS People – support available to NHS staff.

https://people.nhs.uk/help/

NHSI - Developing People, Improving Care


The Trauma Group – guidelines and research summaries on preventing trauma following Covid-19

www.traumagroup.org




https://features.kingsfund.org.uk/2021/02/covid-19-recovery-resilience-health-care/

https://features.kingsfund.org.uk/2021/02/covid-19-recovery-resilience-health-care/

https://people.nhs.uk/help/



http://www.traumagroup.org

helping nhs leaders, teams and individuals to recover from

Documents