Last reviewed 2 July 2020

Tricia Palmer, HR consultant, leadership expert and personal coach considers how the NHS has sought to protect staff wellbeing through the most destructive outbreak in its history.

Containing the corona-coaster

On 8 April 2020, a programme of free mental health support was announced for the NHS’s 1.4 million staff1. The Chief Executive of NHS Practitioner Health, Lucy Warner, was quoted as saying: “I don’t want to use war language, but when the crisis hits, we are likely to see NHS staff suffering symptoms similar to shell shock.”

This case study outlines the rationale behind what has been a far-reaching response to an unprecedented challenge. It looks at the wider framework of wellbeing support offered to health and social care workers, and focuses on one workstream aiming to help NHS leaders and managers become “psychologically savvy” in the way they look after themselves and their teams.

Context and overall approach

By the time lockdown was announced in the UK, the NHS response was already at an advanced stage — plans were in place addressing critical factors like bed provision, workforce deployment and, yes, even procurement. Here we are concerned with the way staff wellbeing was prioritised, and how the NHS Health and Wellbeing Support Response for Covid-19 was implemented as the crisis took hold.

The response was led by the new People Directorate, headed by Prerana Issar and Professor Em Wilkinson, respectively Chief People Officer and Deputy Chief People Officer of the NHS. It centred on early recognition that combatting Covid-19 would almost certainly place a heavy toll on the physical, emotional and psychological wellbeing of healthcare workers. At the time of its publication in mid-March, this forecast was bolstered by daily news reports from Northern Italy showing exhausted medics, seemingly overwhelmed by the pressure of demand for care and dwindling resources.

The health and wellbeing taskforce2 established for this work brought together specialists in organisational psychology, trauma recovery, emergency response, change and transformation, mental health, clinical psychology and occupational health. This group’s initial strategy was informed by the evidence about how other incidents of a similar nature had affected the workforces involved, including single incident responses (such as the Novichok incident in Salisbury, the Manchester Arena attack and the London Bombings) through to larger and longer-lasting events ranging from the 1990/91 Gulf War through to the spread of the Ebola virus.

An early output, subsequently used by a wide range of allied organisations and groups including the British Psychological Society, was the agreement of a simple framework to guide the interventions most likely to be beneficial to staff as the outbreak progressed. Initially, this outlined anticipated workforce responses at three stages: “prepare”, “active” and “recover”.

The taskforce agreed some core principles to guide the nature of wellbeing support offered to NHS staff. The following are aligned to the three phases.

Prepare

  • Collective messaging is key — “we” are here, together and behind you.

  • Enhanced line management support — we will make collective decisions — I have your back.

  • Safety provision, honest, open and transparent messaging about how we will keep front line workers safe.

  • Expectation — preparing people for what is to come and how we will support them.

  • Line managers trained and ready to have psychologically informed conversations.

  • Teams who understand what is expected of them and how to work together well.

Active

  • Physical provisions, prompts and messaging to support care of basic needs.

  • Places to decompress — even if not frequently used — serves to emotionally contain and demonstrate “we are here together”.

  • Clear protocols for normalising stress response, opportunities for debrief and networks of support within the workplace.

  • Anonymous opportunities for discussions.

  • Line managers trained in signs of stress and trauma — specialist psychological services equipped to respond.

Recover

  • 12–24 months post active period.

  • Can take a while to seek help and triggered by other non-related events.

  • Services in place to support the range of presenting conditions, eg anxiety, depression through to PTSD and complex grief.

  • Line managers who know what to look out for and how to manage discussions.

  • Fast access for staff to mental health services where complex treatment required.

  • Return to work strategies which may require short-term redeployment.

These were cross-cutting principles, felt to be relevant across eight streams of work which emerged as the delivery mechanism for the NHS wellbeing response.

The eight workstreams

NHS England and Improvement staff were re-deployed across the eight workstreams which shaped up as follows.

Workstream 1 focused on practical needs — the logistical challenge of getting food, drink and gifts distributed to local workplaces so that staff could feel the benefits quickly. Ensuring that those who needed it had access to accommodation, transport and essential shopping across the country was the primary focus of this work.

Workstream 2 focused on setting up national helplines with partner organisations (including the Samaritans, Hospice UK and the Royal Foundation) — something which was accomplished within a week of official lockdown. Helpline staff were there to listen, signpost people to other offers and to give them emotional support. At the time of writing, there had been over 3000 calls to the helpline and 1400 text conversations.

The service included a 24/7 text service, where staff could immediately have a conversation with a human being. Access to specialist bereavement support was also available, as was practical advice on matters related to personal finances and even relationships (these were identified as common secondary stressors which can overwhelm some employees).

Workstream 3 provided a range of psychological support options, with an emphasis on effective communication and screening to ensure that people were not being given the wrong type of psychological intervention (learning for instance from the evidence3 that a premature de-brief after a traumatic event can prolong or exacerbate psychological damage, however well-meaning or skillful the provider).

One innovation introduced within this workstream was the establishment of a range of virtual common rooms — some of these were “open access”, while others were specialised so that groups of staff could come together who shared personal characteristics or professional backgrounds. Provision was set up in this way in response to an appreciation that users were likely to have a range of different needs, and that some for instance would respond better in conditions of near-anonymity, while others would prefer the sense of safety offered by a familiar group.

Workstream 4 was all about self-help. The project team here negotiated access to a range of apps which could be offered free to staff. These included:

  • Sleepio — an automated sleep improvement programme

  • Headspace — the widely used app for mindfulness and meditation

  • Unmind — a mental health platform

  • Daylight — a smartphone app using CBT to help people experiencing symptoms of anxiety

  • Silvercloud — an extensive mental health support platform

  • StayAlive — a suicide prevention resource.

These were backed by tailored online guides covering topics including personal resilience, financial wellbeing and remote working. Care was taken in messaging around these resources to make clear that they may be useful not just to NHS staff, but also to their families and friends, as part of a general commitment to making relevant parts of the Covid-19 offer as widely available as possible.

Workstream 5 focused on supporting leaders, managers and their teams. The project team enlisted a wide range of expert collaborators from the private sector, the NHS itself, Higher Education and notably from the Centre for Military Leadership (better known as Sandhurst).

The intent was to provide a range of authoritative and immediate resources to guide a community with arguably the greatest potential to affect staff wellbeing — those with people management responsibility. An inherent challenge was about how the project team could persuade hard-pressed leaders and managers across the system to take the time and trouble to use the resources. There is a detailed discussion of how this challenge was tackled, later in this article.

Workstream 6 was about ensuring effective dovetailing between the national wellbeing effort and the work being done by regional colleagues. In essence, the team leading this work was taking a systems leadership role engaging with regional partners to achieve synergy, and avoid the duplication and fragmentation so common across complex systems.

They developed a stock take method early on as a way of quickly gauging local activities and needs, so that for instance it became possible to understand what was happening in individual Trusts and regional bodies such as Clinical Commissioning Groups (CCGs) and ICSs (Integrated Care Systems). Their work enabled other workstreams to engage more effectively with regional actors, and respond to gaps in local provision. One specific example concerned the rapid mobilisation of a range of sleep pods into one hospital which had no space for building and limited nearby accommodation options.

Workstream 7 focused on the specific needs of black and ethnic minority colleagues. The crucial importance of this provision became apparent when statistics were released showing the disproportionate impact of coronavirus on BAME communities — eg that (taking into account age, location and some measures of deprivation, disadvantage and prior health) black people were 90% more likely to die with Covid-19 than white people, while men and women from Indian, Bangladeshi and Pakistani communities had an increased mortality risk of between 30% and 80%4.

The focus of this team’s work was to understand, respond to and educate the system about specific cultural needs and there was an early example of its value when guidance was issued around fasting during the epidemic, linked to Ramadan, which meant that observant Muslim colleagues might need special consideration for the potential impact of fasting on their energy levels. This team was also the conduit for early information about changes to staff risk assessments (altered to include ethnicity as a risk factor) and even the specific spiritual needs of staff who grieve in different ways given their beliefs.

Workstream 8 helped to spread key messages. A group of communications professionals was set up to work across the health and social care system, aiming to maximise engagement with front line and support staff. Their outputs included the building of the people.nhs.uk website which to date has had over 150,000 visitors, and establishing a series of weekly webinars for specific communities of practice to share updates, guidance and emerging ideas.

Initial thinking about the wellbeing requirement

At the outset of the work of the national health and wellbeing taskforce, there was an appreciation that outputs would need to be delivered at pace, and would probably need to adapt continuously in response to changing needs and circumstances. It was also recognised that the wellbeing offer needed to be sufficiently broad and sophisticated to appeal to localities and individuals with widely varying experiences and requirements:

  • the need in Central London would be very different from that just 50 miles away in rural Kent, for instance

  • an active Intensive Care Unit leader would have a completely different perspective on the crisis as compared with, say, a Community Care Co-ordinator, forced to shield at home for the duration of the crisis

  • as quickly became apparent, factors like race, family ties and age had significant influence on people’s priorities and needs.

Other early considerations included:

  • it was expected that there would be continued exposure for a high proportion of the workforce to high and enduring workplace demands

  • the task force anticipated a volume of end-of-life care decisions and serious illness which clinical staff would not have encountered before…

  • …along with a high frequency of “wicked” problems with no clear solutions forcing sub-optimal decision making which in turn would be likely to have negative impact for patients, families and staff involved

  • an expectation of exposure to consistent media and social media coverage where decisions and actions come under scrutiny and are played out in a public narrative which could create strong emotional responses

  • these essentially professional challenges would come on top of personal dilemmas around individual exposure, family commitments, care-giving responsibilities, etc which would be likely to result in deep conflict for some staff members.

The task force was able to draw on evidence from stress, trauma, burnout and psychological growth literature to guide best practice. They were able to consult individuals involved in recent incidents in Salisbury, Manchester and the Grenfell Tower among others, as well as testimonies from frontline and support personnel ranging from firefighters to probation officers able to talk about psychological interventions in the wake of riots and other significant disruptions. Some important conclusions which helped shape the wellbeing offer included the following.

  • Because individuals and teams are potentially at risk from the negative psychological consequences of exposure to trauma, it would be essential to utilise a continuum of stress and trauma models to guide the work.

  • Impact could be in the form of direct or “secondary/vicarious trauma” where the individual is experiencing or listening to the distress of another. The high-profile nature of the Covid-19 response meant that certain staff members were likely to be exposed to news and other commentary about the implications for the wider community of their decisions and actions.

  • Reactions may range between “normal” and “abnormal” to traumatic events that may require some form of psychological or other intervention.

  • Secondary trauma and PTSD evidence indicates a need to avoid immediate assumptions of vulnerability or negative impact, as there are widely documented potential positive psychological consequences of exposure to traumatic events.

  • Evidence from previous incidents of this nature and work with staff groups indicated that some people can be reluctant to undertake psychological interventions delivered by or experienced alongside colleagues within the same organisation. This underscored the importance of remote provision, and aligned with the need to practice good infection control, with an additional benefit of maximising reach across the country.

  • The task force anticipated a slow start to service uptake, highlighting the importance of effective promotion, engagement and endorsement from relevant professional bodies.

  • Services were to be commissioned for 12 months, in view of an expected spike in demand once the initial threat was over. Previous experiences (eg from the Salisbury Novichok incidents) indicated that some staff may still need support such as Clinical Psychology input some 12 months later.

A particularly influential voice within the task force was Professor Neil Greenberg of Kings College London, who brought trauma expertise and a military perspective which chimed with many expected features of the crisis (for instance the need for field hospital style operations in the most hard-pressed sites). Early in the crisis (on 26 March) the BMJ published an article5 by Greenberg and colleagues which provided a practical synthesis of current understanding about how the wellbeing of NHS staff might be affected, and need to be supported through the pandemic. Seven key points from this article are summarised below.

  1. Healthcare workers need to be prepared for the moral dilemmas they are going to face.

  2. Team leaders should help staff make sense of the morally challenging decisions being made…

  3. …[and] take note of staff who are just “too busy” or repeatedly “not available” [for de-briefs].

  4. All team leaders should be aware that no one is invulnerable.

  5. “There is a wealth of evidence that having a supportive supervisor is protective of one’s mental health.”

  6. …supervisors are human too…. senior managers should keep an active eye on more junior ones and be proactive in checking on how they are doing.

  7. Once the “battle” has been won, supervisors should ensure that time is made to reflect on and learn from the extraordinarily difficult experiences to create a meaningful, rather than traumatic, narrative.

The central message here about the significant influence of immediate line managers was picked up by the work done in Workstream 5, and discussed in the next section.

Support for leaders and managers

The project team for workstream 5 was made up of NHS England and Improvement Staff (with leadership, OD and wellbeing backgrounds) all re-deployed for the duration of the project; and supported by a range of external providers and partners. The team’s goal was “to equip NHS line managers to effectively support and lead their teams during and after the Covid-19 crisis”.

Key elements expected to be part of the offer to line managers included online guidance, dynamic resources like videos and podcasts, virtual learning as well as coaching and mentoring support.

The fundamental challenge facing the project team was in providing this much needed support to a hard-pressed management community, in a form that would be immediate, easy to access, and which would resonate with a highly diverse audience.

Available evidence6 about the impact of crisis on workforce psychology and wellbeing made a compelling case that immediate managers have a critical role, and that the quality of supervision during periods of prolonged stress can make the difference between a healthcare worker…

  • EITHER experiencing lasting damage in the form of moral injury or PTSD

  • OR emerging with a sense of greater resilience and renewed purpose, sometimes described as Post Traumatic Growth.

However, it was equally evident that conveying this message — and associated resources to guide managers — would be difficult for several reasons.

  1. Most leaders and managers across the system were facing the most challenging time of their professional lives, and learning was probably the last thing on their agenda.

  2. Previous experience indicated that even those with some time available would find it hard to give themselves permission to seek and use support.

  3. Covid-19 experience around the UK was very varied, with some areas already in full crisis response mode, and others relatively quiet — how to offer support in a form which would be valued by people with such different perspectives, roles and remits.

  4. It was evident that all support would have to be offered remotely — in an organisation where receptiveness to online solutions had not traditionally been warm.

The team’s starting point to arrange a “buildathon” — a virtual agile design event, bringing together around 30 expert contributors from the Centre for Army Leadership, NHS England and Improvement, the Leadership Academy and from the psychological and wellbeing practitioner communities. Using Zoom, the group worked together over two days to create the basis of an offer for line managers. Having a military perspective was considered to be particularly valuable for heightening the group’s appreciation of how the most successful leaders operate in crisis conditions.

The resulting offer comprised a 10-point framework of practical guidance for people managers at all levels, supported by a suite of linked resources available in multiple formats and hosted on the people.nhs.uk website.

Key features were as follows.

  1. The ten-point plan on “leading compassionately through Covid-19” was intended as a plain English, practical and evidence-based summary of the behaviours most likely to promote wellbeing in teams. The detailed behavioural statements are reproduced below.

    1. Look after yourself

      You are not super-human! Who’s got your back? Where is your space to recharge and make sense of the chaos? Paying attention to your own wellbeing will maximise your ability to help patients and colleagues through the crisis.

    2. Speak candidly and compassionately

      To be prepared for what is to come, people need a clear sense of direction and your full and clear assessment of the situation. Balancing your frankness with empathy is essential when your team is under pressure.

    3. Set the emotional tone

      Don’t under-estimate the impact on your team of your actions and the way you come across. Your calm confidence will have a powerful influence.

    4. Be inclusive in the way you lead

      This crisis is highlighting how healthcare inequalities and biases persist, and even become magnified, in pressurised conditions. Consciously and actively inclusive leadership matters now more than ever.

    5. Maintain routines

      Teams who are newly formed and are under pressure need stability. Robust routines for starting and finishing shifts, for instance, can do a lot to ground, induct and connect team members who don’t know each other and may be feeling a range of emotions.

    6. Give yourself space to make the right call

      To make hard decisions in the heat of the moment, you will need to be both rational and intuitive: STOP-BREATHE- REFLECT-CHOOSE. Just a brief moment’s pause will allow you to reconnect with your purpose and values.

    7. Create safe spaces

      Share your own vulnerability. Let your team know that it’s OK to “wobble”, to experience doubt, grief or fear. They will need times and physical spaces to de-stress. They will also need to feel safe to offer constructive challenge to ways of working regardless of hierarchy.

    8. Encourage everyone to talk

      …and to keep talking.

      Crisis situations get worse and last longer without continuous, open and inclusive communication. And the hardest part can be attentive listening when the pressure is on.

    9. Look out for your team

      Look out, in particular, for those driving themselves beyond reasonable limits, those team members who withdraw and seem to reject offers of help, and for those who might feel excluded from the team.

    10. Acknowledge the hurt

      Being a compassionate leader means empathising with the pain your people may experience, recognising that it may endure and taking action. We have a diverse workforce and inclusive leaders recognise the equally diverse spectrum of issues that colleagues face due to their different backgrounds, workload and current restrictions and offer support accordingly.

  2. The microsite hosted a series of authoritative and support three minute guides, each linked to a theme in the ten-point plan…

  3. A range of dynamic supporting resources was developed, including videos and podcasts offering bite-sized guidance from experts like Michael West, and perspectives from leaders and managers across the system.

  4. Leadership Support Circles were developed to provide an interactive forum for managers, described in more detail below.

There were several unplanned benefits that came from working in an agile way to develop the offer. For instance, the design work generated material for a parallel initiative focussing on effective teamwork in a crisis, and also instigated an offer of free virtual mentoring for senior NHS leaders. It also enabled the project team to respond quickly to new developments, ensuring that all content reflected up-to-the-minute understanding of key priorities and concerns as the crisis unfolded. One important example relates to the emergence in April of data showing the disproportionate impact of the virus on BAME clinicians — early appreciation of this critical issue, enabled the team to ensure that inclusive leadership was highlighted and integrated throughout the ten-point plan and supporting resources.

The team felt that the Leadership Support Circle element represented perhaps the most innovative and durable element of the offer. This was (and is) an interactive, virtual format giving leaders a space to come together, share experience and work through the complex challenges arising from responding to Covid-19.

It was felt that, alongside the provision of “push” guidance and support, it was essential to try to offer a way for leaders and managers to connect, and be heard; even with very limited time and many urgent operational priorities, the team’s instinct was that many would value a safe, interactive space like this, if they could get the format right.

The model for Leadership Support Circles (LSCs) was tested with nine organisations and 150 participating managers. It drew on established practices in healthcare including Schwarz Rounds, Care and Compassion Circles — all essentially designed to support the psychological and physical wellbeing of healthcare workers.

A series of LSCs was established, linked to the 10-point plan and structured as follows:

A standard format was devised for all LSCs, emphasising the psychological safety of participants, and intended to ensure everyone attending has an opportunity to be heard. At the time of writing, the approach stops there, without for instance moving into action learning mode to search for solutions.

This is in line with the trauma recovery evidence that in the early stages, the key thing is to provide willing participants with the space, support and structure to process their experiences.

The innovation with LSCs comes through:

  • running them virtually...

  • …specifically for managers…

  • …from mixed disciplines and organisations…

  • …in a one hour format, which provides some learning input…

  • …but which concentrates on enabling participants to share their stories.

Facilitation is undertaken by teams of two facilitators: one in the lead role, presenting input and interacting with the group, while a technical support facilitator looks after the virtual experience, ensuring that everyone is connected, and that the session runs smoothly. The importance of having these two complementary facilitation roles was reinforced consistently through piloting and the subsequent roll-out.

The overall offer to managers was launched on 11 May — effectively what would normally have been a six-month initiative took weeks. Reception for the 10-point plan and supporting resources was universally appreciative — specifically for the direct, practical messaging; and for the fact that the material recognises and provides guidance on reconciling the conflicts managers are faced with in a pressurised context, such as how to be both compassionate and decisive.

To date the most direct evidence of positive impact is coming from participation in the Leadership Support Circles (LSCs). Some key statistics are given below.

Managers

Organisations

Pilot participants

153

9

Participants from 11 May to 15 June

1115

218

Average net promoter rating

91%

Potentially a more important early outcome was the establishment of a national network of LSC facilitators (130 from 66 organisations) with early adopters from County Durham and Darlington NHSFT through Manchester University NHS FT and Guys and St Thomas’ to Cornwall NHS FT. Each of these went through a rigorous development programme starting with careful selection and including:

  • training to be an online facilitator

  • virtual briefing sessions on core LSC content

  • shadowing and co-facilitation over two sessions, with structured feedback

  • supervisory support and CPD after sign-off.

The LSC pilot and rollout has equipped this network with the confidence and skill to facilitate highly effective online learning and support sessions for embattled NHS leaders. Effectively therefore, the NHS has the by-product from this work of a ready-made virtual facilitators’ community.

Conclusion

Now, getting towards July, with the UK looking to relax lockdown rules, it is not easy to look too far ahead. Recent Covid-19 developments have seen nations like Germany and South Korea — considered to be exemplars in the way they have managed the pandemic — experience sharp spikes in their infection rates. Across the NHS, a suitable analogy would be a strung-out marathon field — with some localities and Trusts already looking to establish business as usual, while others are struggling with secondary demand, and talking about the probability (not possibility) of a second spike. In terms of the overall organisational recovery, the consensus seems to be around a period of at least three years and possibly as many as seven.

So it seems likely that the outcomes of the work described here will continue to be relevant and needed by NHS staff, and indeed that demand is likely to increase in the summer months as many clinicians and allied professionals get the chance to truly take stock of their own wellbeing. One important initiative in the coming months will be the work started to understand and promote Post Traumatic Growth (PTG). PTG is a lot less widely recognised than PTSD, despite the fact that it is (according to authorities like Martin Seligman7) the more likely outcome for someone who has experienced prolonged stress. A current focus of design and testing in the wider NHS wellbeing programme is in finding ways to help managers and staff talk about what they have experienced so far, and to open up understanding about:

  • the potential for PTG

  • what the indicators of PTG are

  • how organisation and managers can act to maximise the prospect that PTG is what staff experience in the aftermath of Covid-19, rather than the damage more usually associated with distressing and traumatic episodes.

This article has been written in consultation with Darren O’Connor — Director of Passe-Partout leadership consultancy.

Footnotes

1NHS staff to be offered mental health support for Covid-19 “shell shock”, Guardian, 8 April 2020

2See the NHS People microsite for details of task force members: https://people.nhs.uk/about/

3Eg psychological debriefing for preventing post traumatic stress disorder (PTSD) (2002), Rose, Bisson, Churchill & Wessely

4ONS: Coronavirus (Covid-19) related deaths by ethnic group, England and Wales, published 7 May 2020

5Managing the mental health challenges faced by healthcare workers during the Covid-19 pandemic, Neil Greenberg, Mary Docherty, Sam Gnanapragasam and Simon Wessely; NIHR Health Protection Research Unit In Emergency Preparedness and Response, King’s College London

6Prominent contributors include Andrew Jameton, Neil Greenberg, Michael West, Richard Williams and Esther Murray

7M Seligman (2011) Flourish