By Dr Jeanne Hardacre, Founding Director, Impact4Health & Dr Alexander Margetts, Clinical Psychologist, University of Leicester

We have just spent 5 days as members of the newly-formed Training & Education Faculty for NHS Nightingale Hospital London. Alongside the phenomenal core team, we and others have been immersed in helping to shape, define and road-test a sustainable, scalable methodology for preparing staff for the work they will be doing in the largest Intensive Care Unit (ICU) in the world.

The work is ongoing, and we have not yet had a chance to fully process our reflections. However, we have some early safety-critical insights which we feel it is important to share quickly with clinical, strategic and operational leaders at all levels. We know people leading colleagues right now through these extraordinary circumstances need pragmatic, relevant and practical help, not theory and rhetoric. We offer this blog on that basis.

Keeping staff safe must be a top priority in this Covid-19 environment. No matter how large or well-equipped the hospital, without its workforce, it cannot save patients. It is this that is galvanising movements to insist on routine testing and providing full Personal Protective Equipment (PPE). In a similar way, if we do not guard ourselves from the psychological effects which accompany this work, we may inadvertently and potentially cause harm to our mental health and wellbeing, both short and long-term.

Every leader and team member in healthcare has a key part to play in this; in the tone we set, the way we behave, and in the practical support we make available. So, how do we quickly create a culture where staff safety and wellbeing underpins the quality of our care for patients?

Based on work from the pre-Covid-19 era on psychological safety^1,2, “just culture”³ and cultures of high quality care⁴, we have observed three priorities:

1. Safer Expectations: what we expect of ourselves and others needs to be realistic, honest, and gentle. Our habitual mindsets of striving for perfection, admiring “heroic” self-sacrifice, and upholding rigorous self-critique are at best misplaced, and worst potentially damaging in this harsh Covid-19 context. The safety of our patients is usually foremost. With Covid-19, the safety of ourselves and colleagues must come first. This may feel counter-intuitive, but if we are not physically and psychologically protected, more of us will become ill, and our patients will be less likely to be treated and recover.

2. Safer Conversations: we have to acknowledge the fear and uncertainty we are all feeling, without shame. We must name and normalise these emotions, giving each other permission to emote and talk about them. Key to this is creating and embedding safe spaces, safe places, and safe processes, to have the conversations we might otherwise avoid. Building on and refining methodologies and models from Human Factors, we need to move from a rational, objective approach to pre-briefing and de-briefing, to one which places human emotions and feelings at its heart. Every day effectively becomes a Schwartz⁵ Round for our clinical, management and leadership practice.

3. Psychological PPE: we must think about and enhance our mental health and wellbeing, now, and after, working in Covid-19 units. Just as we ‘don’, ‘doff’, and monitor our physical PPE, we need to check our (and others’) “Psychological PPE”. Together with the wider Wellbeing Faculty Team, we have started to develop an evidence-informed skills training session to enhance self-care and resilience, and hopefully mitigate burnout, moral injury, compassion fatigue, and PTSD^6,7. This should be a part of core mandatory induction training for all staff, clinical and non-clinical. Even for those used to challenging ICU environments, it is important to acknowledge some of the unique aspects of Covid-19: higher mortality rates, ever-changing teams and shift patterns, personal and family health threat and anxiety, rapidly-adapted buildings and treatments, all whilst under press scrutiny and public idolisation.

We hope that by sharing our early experiences and learning insights, we can co-create with you and others the safest culture, most appropriate leadership responses and most effective ways of educating colleagues, helping all of us feel relatively safer as quickly as possible in these unprecedented circumstances and rapidly-evolving times.

Author contact details: jhardacre@impact4.co.uk / a.margetts@nhs.net

References

1. Frazier, M.L. et al (2017) Psychological Safety: A meta-analytic review and extension Personnel Psychology 70; 113-165
2. https://blog.dropbox.com/topics/work-culture/amy-edmondson-on-the-power-of-psychological-safety-in-distribute accessed 4th April 2020
3. Marx D. Patient Safety and the Just Culture Obstetrics and Gynaecology Clinics of North America. 2019 Jun; 46(2);239-245
4. West, M et al. (2014), Collective leadership for cultures of high quality health care, Journal of Organizational Effectiveness: People and Performance, 1(3); 240 -260
5. Pepper, JR., et al.(2012) Schwartz Rounds: reviving compassion in modern healthcare Journal of the Royal Society of Medicine” 105; 94-95
6. British Psychological Society (2020) The psychological needs of healthcare staff as a result of the Coronavirus outbreak
7. Guidance for planners of the psychological response to stress experienced by hospital staff associated with COVID: Early Interventions (2020) Covid Trauma Response Working Group Rapid Guidance

Dr Jeanne Hardacre

Jeanne is an organisational behaviour specialist with a background in developing leadership, teams, organisational culture and human systems. She works independently and has over 20 years’ experience developing and supporting clinical and healthcare leadership teams across a wide range of services. Jeanne volunteered as an early member of the Education and Training Faculty at NHS Nightingale in London, helping to set up and develop training and support for staff preparing to work there.

Dr Alexander Margetts

Alex is a Clinical Psychologist and BABCP accredited CBT therapist with experience in working with individuals presenting with common mental health difficulties. He is currently a Clinical Tutor for both the Leicester Doctorate in Clinical Psychology and Royal Holloway IAPT CBT Training course. Most recently he has worked with the Education and Training Faculty at NHS Nightingale London, to help develop their mental health and wellbeing training for all new staff working there.