Staff Wellbeing in Crisis

Staff Wellbeing in Crisis

Protecting Staff Mental Health Through Covid-19

There are still plenty of things that individuals, teams, and services can do to minimise the traumatic impact on individual staff in the impending pandemic “peak”.

The following are action points extrapolated from two key review papers. Links to those papers are provided below. Emphasis is on current staff mental and emotional well-being and reducing the risk of future sequelae of trauma.

All members have a role in the health of the team, but some individuals, on behalf of the organisation, hold explicit responsibility for the health and efficacy of teams. To highlight this I have created separate lists for individuals and those with specific leadership responsibilities.

Individuals:

  • Competence and efficacy. Feeling competent and prepared helps to protect you from negative outcomes. Practice procedures. Satisfy yourself that you are ready. If there is an area you feel less confident of, seek support and develop a plan.
  • Motivation. Motivation is protective. Remind yourself how important your work is.
  • Fitness improves your resistance to emotional strain. Use proactive, strategies to stay mentally and physically well. Don’t deny. Use action to distract. Exercise, relax, fix something, meditate – whatever is familiar and suits you. Make relaxation a skill. Use planned problem-solving. Hold back on alcohol. Avoid drugs.
  • Being integral to a team is protective. Plan together. Rehearse the plan for the day. Practice skills. Share successes as well as fears and other reactions. Do not stigmatise feelings, either in yourself or others.
  • Secure your secure base. Satisfy yourself you have done what you can to protect yourself and your family. Practical steps; insurance, wills.
  • Social connection is protective. Connect with friends and family. Don’t expect them to understand what work is like, exactly. Spend quality time with them, even briefly. They will want to help you but may not know how. Make clear requests.
  • It helps to feel effective. If you need quarantine, use this time away from maximum exposure to recharge your emotional batteries. If it frustrates you to be prevented from work, find something you can do to support the team – revise protocols etc.

Leadership

  • The wellbeing of team members depends on being and feeling Safe, Skilled, Connected, and Prepared. Make every effort to ensure all team members have the skills and the equipment to do their work safely and well.
  • Team spirit and morale protect. Make yourself accessible to team members. Encourage supportive relationships within teams.
  • Preparation protects. Train team members, and rehears roles, skills, and communication. Establish key phrases for difficult moral decisions, such as “your own oxygen mask first.”
  • Belonging, and team morale are protective. Meet and share. Normalise (do not mandate) grief, doubt, frustration, fear. Celebrate positives, like cohesion, team spirit, tenacity. Identify learning if it can be operationalised. Divert from stigma and blame, including self-blame. Include all, including reception and support staff.
  • Communication is key. Establish regular times for sharing information and updates.
  • Appreciated voluntary contribution protects. Take seriously, and find a way to act on, any suggestions from individuals. As much as possible enable individuals to feel in control of their work.
  • Vulnerability to trauma varies between individuals and between roles. Know your team members and be aware of early signs – fatigue, poor sleep, health worries, avoidance, increased alcohol use. Act early to support.
  • Sharing protects. Try to avoid individuals having sole responsibility for areas or individual patients.
  • Traumatic harm is cumulative Consider rotating a team member through roles to reduce overall exposure.
  • Competent contributing protects. If rotating team members into less exposed situations ensure they understand they are recharging their batteries, and still have a skilled contribution to make. Train them in that skill if they are not confident.
  • Individuals differ in what they need from down time and support. Have a flexible approach to support and down time and agree this with individuals. Establish a stepped approach to support in the organisation. Support the supporters.

Source material can be found on the website for the Association of Anaesthetists. These are review papers summarising findings from research carried out during and following the SARS pandemic:

A Systematic, Thematic Review of Social and Occupational Factors Associated With Psychological Outcomes in Healthcare Employees During an Infectious Disease Outbreak (PDF) Brooks et al JOEM Volume 60, Number 3, March 2018,

Traumatic stress within disaster-exposed occupations: overview of the literature and suggestions for the management of traumatic stress in the workplace (PDF) Brooks Rubin and Greenberg 2018 British Medical Bulletin, 2018, 1–10 doi: 10.1093/bmb/ldy04

Andrew West April 2020 2/2

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Horse-Whispering

Horse-Whispering

In Being With and Saying Goodbye I have concentrated mainly on the work that can be conducted through conversation of a fairly decorous and measured variety, even if not always using verbal language. There is a species of Being With that I neglected to mention. Thinking about it now, it is easy to imagine why. If you read on there is a possibility that you will be offended by the analogy that I draw, but I hope you can bear with that and get to the point I am trying to make.

The mental health problem that people fear most, I suspect, is that of totally losing control; of ceasing to be human. My hunch is that this is where a lot of the stigma against mental ill-health comes from. Instead of addressing that fear and stigma, society busies itself with surface psychology. Money and rhetoric are poured into this to reassure us that plenty is being done. Meanwhile, those with fear of fragmentation go round the mill of medications, revolving doors, and pejorative labelling. I think that they often feel profoundly alone and abused. This is the opposite of Being With.

I suspect that in BWSG I neglected this aspect through shame at how much fear I can feel myself and how much I can shrink from accompanying those gripped by that lonely fear. I am less afraid when wearing my work clothes. Power has its advantages.

This omission from BWSG occurred to me recently when I was talking to someone who re-trains ex-race-horses so that they can be ridden and loved in a second career. It recalled a conversation I had had shortly before with the extremely anxious parents of an incredibly anxious child. He had probably always been fairly anxious, but had managed it through his prodigious talents and sheer effort of will. Something had caused this approach to fail, and he had been sent plummeting into a vortex of sheer terror, when there is no floor and where successful omnipotence, potent parents, and the phantasised all-powerful benign oversight, are exposed as mere clay and collapse crashing all around. He was terrified.

In discussing this with the parents, drawing on past experience to try to advise them, I found myself explaining that for the time being at least they had to acknowledge that they could not hope to interact with their son in any way that was familiar to them. The analogy that seemed to help them was that of being in the presence of a very frightened animal: A spooked horse, perhaps.

I have been in the presence of terrified people. It is something that my formal training did not address very well, so I fall back on my native character, inherent and shaped over the years. The closest to explicit training that approaches this would probably be that hopelessly clunky bit where they tell you where to sit in relation to the door: I and the “other” are expected to be reassured by the fact that each of us can run out of the room if we have to. The image that this always evokes in me is of us colliding, jammed, in the doorway in a mutual rush to escape. To be fair there is some merit it getting us to think about our positions in the room. Position is power and power corrupts. We need to be big enough but not too big; friendly enough but not too friendly. But it doesn’t allow for the encounter on the stairs, for example. We are also taught about breathing rate, pacing, and such-like. Sure enough, it is useful to be aware of these things as well (there is so much to be aware of), but at the start of the meeting, as the whole family come in, I don’t want to look as though I was trained by the SAS.

And so, occasionally, there comes a point where I realise that there is a terrified animal in the room with me. Why does this apparently demeaning analogy help? What is the approach that it evokes?

In the presence of this terrified being, with whom there can no longer be any normal social interaction, we resort to sounds and behaviours. There are three tasks. One is to reduce the threat. We (I say “we” advisedly because there is pacing and matching going on – that is part of the point) – we manage eye contact differently, soften the voice to soothing sounds, and position ourselves in the space so that the other feels neither abandoned, nor encroached upon or trapped. The second task is for me to manage myself. There is no merit in being unthreatening if I, the parent or professional, am obviously terrified. I must at least appear as though I am intact and unthreatened; undaunted by the vortex. This is easier to project if it is the truth. The third task is to re-establish some semblance of conversation with the other person. No use, though, expecting my words to be grasped and responded to in kind. It is more likely that, whatever words I choose, the meaning conveyed will be “I am OK, we are OK, the world is OK, it’s OK, you can be OK…”. It is more like a dance, or a musical improvisation. I am situated and relaxed in the world and I am inviting you to mirror me because if you do, then I think you will feel more in the world as well.

Now here is a problem. If I managed this moment successfully, and the parents were with me, then I have modelled what may be a new behaviour for them. But they are unlikely to be able to replicate it straight away. When this situation is behind us, the parents usually have to return home with their child. They will ask me what they should do in a recurrence. I will make some suggestions, but instruction under these circumstances inevitably become clunky, like the training we receive. How many times have parents been told to “make sure all knives and sharp implements are out of the way”? This is like “sit equidistant from the door”. It is all well and good, but it is impossible. We cannot make the environment safe – only safer.

It is the attempt to make situations totally safe that result in abuse – what is sometimes called iatrogenic abuse, though this hurts me – it is not only doctors who are guilty, and most of us do the best we can. Going back to the first and second tasks, above (reduce the threat, and manage my own fear) there will come a time when this cannot be done. What do we do then? Well, here are two examples from early in my training, before I started specialising in Child and Adolescent work. Go easy on me. I was a kid myself:

  1. An adult male ran – barefoot, as it happened – first at the wall and then at me, in a corridor. I stepped to one side and let him pass. I followed him some way out into the street, gave up the chase, and called the police.
  2. An adult female, at a similar stage in my training, slapped me in the face. I shouted at her, “Don’t ever do that again!” and continued the assessment.

The genders in these vignettes are telling. This is about power. In the first instance I knew I was outgunned and I called on a service that I knew would not be. What they did, was out of my hands. In the second I believed myself to be the more powerful, in a crude, physical sense. When the chips are down, the world we live in is physical. I exploited, perhaps, her past experience of abuse and her fear. I did so entirely on reflex and out of instinct. The fact that we were able to sit again, and to return to talking, reassures me to some extent that she felt safe enough. I knew I had made a mistake – it would be years before I knew enough about myself to guess that the mistake was likely to be that I had shown too much of my smart-Alec. But the point is that the container has to be capable, physically, of containing. And it has to imply that capacity without resorting to it. It is another impossible paradox that we manage as best we can.

I want to return to the animal kingdom. It is a useful analogy because it makes explicit the fact that we have regressed, in this situation, to a pre-verbal level of existence. At these times we call on our animal avatars. What would I like my avatar to be at these times? I would like to be an elephant, caring, wise, and benevolently invulnerable. But I have to be nimble enough to step to one side without trampling. I know, also, that I can show my cornered tiger. I hope that I have learned its power, so that all that is needed is the bearing of teeth in a smile, or the raising of a bushy eyebrow. It is a tough (beautiful) brutal world. I may be able to help you if I survive.

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