Coronavirus: caring for the carers

At the height of the Covid-19 crisis, staff working in hospitals and residential homes went above and beyond in often extremely challenging circumstances. However, there can often be a mental and emotional health reckoning when things return to ‘normal’, as one healthcare organisation has recognised in its employee and manager support programme. Dr Andrew Hilder reports.

Ludlow Street Healthcare Group is an organisation of nearly 1,100 staff working in hospitals and residential homes supporting service users with complex mental health problems. Like every other healthcare organisation, our staff responded with unquestioning professionalism to the Covid-19 challenge. We were of course also under enormous strain, having to adapt to ensure we could respond to the swiftly escalating risks of the pandemic.

This article is going to outline how we have gone about supporting our staff in their mental health and wellbeing through what was, and remains, a very challenging period.

The context

As an organisation, we identified that, as we moved out of the initial “crisis management” phase of managing Covid-19 and into what we might term a more “business as usual” phase, the impact on our staff’s mental health would start to become more pronounced.

We anticipated that people, already weary from the emotional and physical strain of the initial weeks, would have more time to reflect on the impact of the virus on the lives of them, their families, friends and colleagues and also those of our service users and their families – both now and for a potentially long time to come.

We therefore felt it was important to offer an evidence-based support approach to help all our team cope with the difficult feelings they would now likely experience after the initial phase

We recognised that offering a structured staff wellness support package would become one the most important components of keeping us coherent as an organisation as well as able to deliver as smooth and safe a service as possible over the remainder of the year. In particular we noted:

• The initial crisis could exert substantial pressure on the staffing situation for a minimum of a further nine months or until a viable vaccine was developed that allowed more normal social and economic functioning to re-emerge.
• It was possible this timeline could be extended further should there be problems with viral mutation, vaccine development or in the development of even more severe (but lower probability) secondary effects (for example significant problems of social order or large-scale economic failure).
• Non-Covid-19-related sickness might reduce because of staff unwillingness to admit they could not cope. We were concerned the predictable crisis-related behavioural activation, team cohesion under stress, and the cultural tendency of healthcare professionals generally to adopt a stoic attitude to stress and disease could result in presenteeism and high levels of unmet need in our team.
• We were aware the initial “heroic” response could not be sustained, particularly with everyone importing stress from their everyday lives and being continuously challenged by the social, psychological and economic consequences of the active pandemic phase.

Developing our staff wellness support strategy

We identified a staff support strategy was needed to take the organisation through this period. It needed to be robust enough to react to unpredictable changes and constructed in such a way that each layer of the organisation received support in line with a predictable and safe process.

It was recognised the strategy needed to draw on the input and expertise of differing departments within the organisation; so a team was brought together comprising representatives from the clinical, human resources and communication teams.

We then centred our strategy around the important principle that the biggest source of perceived support in the workplace comes from peers, and that the biggest general reported source of (non-role-related) stresses are managers perceived to be emotionally and relationally absent or unsupportive and/or evasive and guarded with information.

Consequently, we set five clear aims for this support strategy:

1. Universal access to agreed support processes and materials.
2. Clear and continuous communication of the strategy to maximise understanding of the benefits to the individual and buy-in.
3. Equip our teams to orientate around high levels of emotional demand.
4. Maximise attendance and minimise avoidable psychological morbidity.
5. Support each staff cohort and workplace to be perceived as a source of support through this period.

The strategy framework

To achieve these aims, the strategy framework comprised six core elements:

• Development of a wide range of support materials and regular forums delivered in formats that would maximise engagement and participation.
• Triage processes ensuring that staff who need more tailored support were helped effectively and absence and distress is minimised.
• In-built processes to ensure that specific and thematic feedback could be escalated up through the organisation and inform corporate governance decisions and actions through the pandemic period.
• Provision for managers of additional psychologically-based training for managing staff during periods of high uncertainty and anxiety, where baseline levels of psychological morbidity were expected to be high.
• Processes should leverage existing strong, familiar relationships.
• A layered approach to ensure universal coverage.

These elements would be delivered through a layered support approach, split between individual, peer, team and manager support. We shall now look at each in turn in more detail.

Level 1 – individual support

All staff have been made aware of a resource library of wellness support materials on the organisation’s intranet that is constantly updated with new resources, sourced from wide-range of organisations, but all vetted by the clinical team.

In recognition of the fact people have differing communications preferences, and might prefer to read wellness materials in the privacy of their own home, the materials are also available via a web page that can be viewed externally and at any time, www.lshealthcare.co.uk/staff.

Each staff member has also received a 60-page self-care guide which they have been encouraged to take home. In clear sections with everyday language, the guide provides simple ideas for how to support yourself, as well as your friends, families and colleagues. https://bit.ly/LSHSelfCareGuide

Level 2 – peer support:

Each operational work unit is encouraging:

• Open communication of levels of stress and distress.
• The ability of staff to identify signs of burnout and stress in others and to mutually support and if necessary signpost each other to external help.
• Frequent positive behaviour feedback and reinforcement and the promotion in teams of overt behavioural indicators of gratitude, kindness and acknowledgement of selfless behaviour that supports the team to continue functioning.

Through the work units and the self-care guide staff are encouraged and prompted to consider further means of mutual colleague support, including:

• The promotion of online but out-of-work communication and mutually-supportive peer relationships such as WhatsApp groups etc. Communal activities within such groups such as quizzes, games and so on – on a “drop in basis”.
• The presence of “positive boards” in staffrooms where staff can write grateful messages to the team and to each other (subject to this being seen as culturally appropriate in individual settings).
• Formal “buddy systems” to ensure that, when staff need to go into self-isolation or need bereavement support, a peer is allocated by the team to make sure that contact is retained with the person.
• Staff taking turns to oversee and collate collective idea generation systems, such as ideas boxes, activity ideas for the team and so on, to ensure there is a continual flow of engagement and feedback throughout team members.

Level 3 – managers supporting teams

This level of support encompasses:

• The presence of identified, reliable and psychologically safe line management support was judged likely to be one of the biggest factors in supporting employee wellbeing and attendance during this period.
• All line managers now set aside at least one hour a week for the teams they directly manage to attend “drop-ins” – designated voluntary weekly Q&A timeslots where questions can be asked and either answered or escalated to the next level for a response. Drop-ins also seek feedback on the teams’ experiences of work during the week.
• Line managers can also attend their own weekly Q&As facilitated by middle managers, ensuring the same specific and thematic feedback opportunity for line managers.

Level 4 – support for managers

It was recognised managers would be under considerable additional pressures during the height of the pandemic, and would also need to be offered specific support and the opportunity to feedback and discuss alongside peers the problems they are facing. It was also felt they needed to be supported to problem solve solutions and palliatives in a psychologically safe environment.

Accordingly, cohorts of middle managers in each operational unit are offered attendance at support sessions facilitated by senior and clinically-experienced staff.

As well as involving components of reflective practice, these groups are informed by the organisation’s existing “action learning set” protocol. These sessions give managers the opportunity to discuss specific and thematic issues raised in the support sessions they provide.

They also support managers to signpost staff who may be struggling more to specific individual support.
Finally, group facilitators feed back the specific and thematic content of these groups to the relevant corporate governance forum.

Conclusions

Ludlow Street Healthcare’s overall strategy has been informed by the relevant evidence base, principally “psychological first aid” and, in particular, the assumption that peer support is usually the most important component of each individuals’ support experience.

Therefore, permission-giving and the encouragement of supportive routine conversations, was given greater emphasis than formal processes.

Formal processes were also incorporated to ensure staff were aware of visible organisational indicators of organisational concern and that feedback was both sought and responded to.

This was driven by the awareness that communication is often the first casualty of crisis – we felt that if any of our team was not given clear access to a place where they could both feedback the experience of work and be confident of receiving feedback, we would risk large amounts of unmet need and staff distress.

Accordingly, we adopted the familiar “stop, keep, start” process for staff feedback into the scheduled sessions to ensure we both received feedback about any organisational responses that were unhelpful, but also that staff were encouraged to escalate ideas of how the workplace could be improved during the period.

A major challenge for all multi-site health and social care organisations throughout the pandemic has been to foster an aligned sentiment of mutual care for people working in diverse roles and working with differing client groups during the crisis. The analogy of playing chess on a moving chess board came to mind when considering the strategy that was needed.

Also important was fostering a bottom-up approach rather than implementing mechanistic “wellbeing” interventions that are sometimes easily dismissed, have low face value and, at their worst, may discourage those who may actually need more enhanced support from engaging.

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Further, the paradox that mental health staff are often most resistant to acknowledging their own distress and stress had to be acknowledged. The complex reasons for this are not possible to explain in this precis of our strategy, however, the awareness of the cultural position of a team was critical in tailoring the right kind of support.

The pandemic has changed many assumptions about organisational processes. We are hopeful that the interventions and on-going consultation processes we have put in place will allow us to support all our staff to cope with the impact Covid-19 will continue to have on all our lives for some time to come.