The changing profile of staff support

During the Covid-19 pandemic, we learnt more about the power of connection and coming together. We were reminded how work can connect us socially, or isolate us, and everything in between. Social isolation is bad for health. As Michael Marmot wrote in 2015's The Health Gap, it is one more indignity that follows the social gradient – not just more adverse things happening, but fewer potential social supports coming from a variety of sources.

The pandemic has also been a time when healthcare staff wellbeing has come to the fore, in both the public realm and in psychological working. Prior to this, psychologists and other health professionals commonly provided staff support additional to their clinical roles (particularly those working embedded in medical contexts), but there is little described about the work. Here, I will briefly consider why it is important to support healthcare staff psychologically, offer a working definition of staff support, and look at how the profile of staff support has changed. It has become more prominent, and what psychological staff support includes now goes beyond direct work with individual staff or teams, to working organisationally and thinking about crucial contexts.

Why support healthcare staff?

We know that at a fundamental level, supporting people to do their work makes sense and, as the NHS Constitution for England (Department of Health, 2021) states, 'is the right thing to do'. Another significant reason for supporting healthcare staff psychologically is due to the impact of working in healthcare on staff mental health. Healthcare (particularly in physical health) working commonly involves repeated exposure to suffering and pain, death and dying. Sometimes the work has a cumulative negative effect. Although, on the whole, the challenging nature of clinical work does not mean that all healthcare staff are traumatised and need (psychological) staff support.

Pre-pandemic levels of stress and burnout were already high in healthcare staff, having a clear bearing on sickness absence, turnover rates, and staff shortages. Certain groups of staff are likely to be more disproportionately affected by workplace stress than others; systematic inequalities in health outcomes between social and ethnic groups (Marmot, 2015) impact on staff when they are giving care and when they/their family receive care. Institutional and interpersonal racism operate within healthcare organisations too (Olusoga, 2022).

We know that healthcare staff who are from ethnic minority/global majority populations are more likely to face discrimination at work, have disciplinaries, and be disproportionately affected by physical and mental health issues. We also know that certain groups of staff in healthcare, such as those on lower incomes, male staff, and ethnically minoritised groups, face barriers in accessing wellbeing and psychological interventions. We must think deeply about how to improve access to staff support services for these groups and how we address issues that healthcare staff experience such as discrimination. We need to consider our role in affecting real change in EDI within staff support so that it is not a tick-box exercise where EDI stands for 'Endless Distraction and Inaction' (Ahsan, 2022). Raselle Miller, in Chapter 1 of our book, notes that "While you may be in a formal supporting role, you are also a stakeholder in a fair and equal society. If you recognise yourself as someone who holds a form of ethnic or racial privilege, being an active accomplice to change means amplifying the voices of marginalised people, not using your position to speak for them.' Miller goes on (p.35-36) to give the following suggestions for indirectly supporting individuals through learning and being an active accomplice to change:

Get to know the issues

Like learning anything new, start by reading, listening, and educating yourself about the complexities of the issues you will be confronting. A search engine is a great resource for any question you might have (and you don't have to worry about how offensive it might sound). If you do have an opportunity to speak to colleagues about their experiences as part of your learning journey, listen and be compassionate about the challenges they face. If you are asking them to support your education, remember you are not entitled to their stories, time, and energy. Let them know they can decline.

Use your therapeutic relationship skills

Remind yourself of what creates a supportive and respectful relationship. An awareness of your own culture and biases (we all have both), letting go of any assumptions, being curious, and open to learning about the person and their experience (including allowing them to teach you) are key to building trust (Ade-Serrano et al., 2017).

Take considered risks

Be aware of the language you use. If you are unsure how to pronounce a name, having a go shows trying. You can also ask what someone would like to be called. Ask how someone identifies – whether this is their nationality, ethnicity, race, or language. Perhaps you can share your identity too. This sends a clear message that you haven't made an assumption and it creates the opportunity for someone to open up if they wish to.

Notice your interpretations or assumptions around the intent of a person's behaviour or communication style – for example, eye contact or use of gestures. Take a risk by being curious about how you are understanding or being understood by a person, or within a group.

Make your commitment visible to (the right) people

If you have learnt something, don't feel the need to prove what you know to your friends and colleagues from marginalised ethnic groups (this then becomes performative virtue signalling, not solidarity). Instead, send the information, book, podcast, article, and event details to someone who has a smaller knowledge base than yourself. Your new knowledge will speak for itself to those who are already committed to change.

What is staff support?

The loose premise of staff support is that staff have been affected by their work or that their ability to work has been affected by something. In practice this is not an easy distinction to make, as the work may involve supporting individuals and teams related to a distressing incident on the ward, but it may also be that something outside work is combining with workplace stress to have an impact.

Staff support is different to therapy because it involves a collegiate relationship rather than a client/patient therapist relationship. In some instances, we may support staff at the same time as working together with patients and families. So, we may experience similar stresses from our shared workplace. This throws to light questions and dilemmas around the boundaries of confidentiality and how we protect this.

The focus of the work is broader than individual and team concerns though. It is necessarily strategic and operates at an organisational level, and therefore cannot ignore systemic and workplace issues that cause stress and mental health problems for staff.

So, if, like me, you sometimes feel the work is a bit slippery and vague, turn to Julie Highfield and Adrian Neal, chapter 15 in the book, who outline various roles psychologists can have working in staff wellbeing in different ways across an organisation. They discuss changes in staff support working and introduce the concept of influence as a practitioner psychologist, comparing and contrasting formalised roles of staff wellbeing and authorised influence versus other more traditional roles for psychologists and informal influence.

Long overdue

In the realm of staff support there is a striking difference between the profile of professionals working in staff health and wellbeing before and after the pandemic. Before the pandemic, people were interested, sure. Some organisations had already placed staff wellbeing more centrally to their work than others, and in some hospitals, there were dedicated staff psychologists or those with allocated time to do this work. However, this was not commonplace and certainly many psychologists and other professionals struggled to find the time (and managerial and system backup) to do this work. Time and again I have heard that supporting staff is not direct clinical care and not income generating, so a luxury use of precious psychology time. In my experience, leaders and the system not valuing staff support can in itself become a stressor by denying that staff are experiencing stress or mental health decline.

Yet at the same time, discussions about staff wellbeing and the 'human factors' associated with healthcare have become more commonplace. We have also seen a rise in 'author clinicians' writing books on their experience of working in healthcare which inevitably touch on the impact on their own wellbeing (Clarke, 2017; Marsh, 2014) and on being on the receiving end of care (Gawande, 2014; Kalanithi, 2016). While working on this book, I kept hearing that this is a book that is long overdue. There is a wealth of literature in organisational development (OD) and organisational psychology related to teams and organisations. But what of staff support working involving psychologists (and other wellbeing practitioners) who work clinically in healthcare?

Since the turn of the century there have been many articles researching the wellbeing of healthcare staff in acute physical health contexts looking at burnout, PTSD, coping, and resiliency (for intensive care settings in the UK, see various articles by Gillian Colville and Julie Highfield). Such findings tend to point to the importance of having time for staff to connect in huddles or use supervision/reflective practice, although there are few publications that explore the effectiveness of this. One example is D'Urso et al. (2019). Specific interventions in healthcare have been outlined, such as Wallbank's (2016) model of restorative supervision and in the UK, some have written about working in organisations and healthcare broadly (Obholzer & Roberts, 1996; Campbell, 2000; Wren, 2016). Lately (no doubt spurred on by the pandemic's pressing need) we have seen several books on healthcare staff wellbeing, including nurturing maternity staff (Smith, 2021); looking at healthcare staff mental health (Murray & Brown, 2021); wellbeing and spirituality of health and social care professionals (Aris et al., 2021); trauma-informed organisations (Treisman, 2021); and reflective practice in healthcare (Kurtz, 2020).

Misguided notions

So, it seems true that prior to the pandemic there was not much published about staff support in (acute) physical healthcare settings despite the work having gone on for years. Why is this? We have touched upon how general staff wellbeing has been largely undervalued due to the priority of clinical (seeing patients) activity and focus on (direct) income generating work. This means that in some areas psychologists are simply not allowed to do this work. Sadly, this not only demonstrates that staff support is not highly regarded in some health organisations but also reflects a short-term view of workplace wellbeing.

This lack of value and short-sightedness can mean that even if there are staff support measures in place, staff are not released to attend or there are not sufficient structures backed up by senior leadership and resources to scaffold the work.

Staff support not being valued or prioritised can also be linked to stigma in help-giving professions; clinical staff may feel the need to act with bravado, may have concerns about career progression or having their fitness to practise questioned if they admit they need help (Mildenhall, 2021, p. 55). Staff may be influenced by narratives such as how can heroes ask for help or heroes don't need to ask for support. Traditionally, doctors (and perhaps any healthcare staff) have been resistant to the idea that they might benefit from or need support. 'Not being able to cope' was seen as a sign of weakness; asking for help was 'giving in'. There had been a misguided notion that, because they are trained and qualified to look after others, they should not need to be looked after, mentally and emotionally, themselves (Morrison, 2021, p.96).

Sometimes staff and organisations do not see the work as serious; in one place I worked staff support was referred to as 'fluffy'. Some talk about generational differences and sometimes this is described in polarised negative terms with staff support seen as something needed more by the younger, touchy feely, or 'snowflake' generation. Conversely, the older 'battleaxe' generations' approach to workplace and organisational stress was as something they went through, so junior colleagues must also endure them.

However, with the pandemic we have seen a shift in this, with those individual staff and areas who previously may not have considered staff support seeking it out for themselves and staff in their teams. To borrow the words of Cream and Wang (chapter 16), we have seen 'Covid-19 as proxy' – as everyone was affected, it helped reduce stigma about help-seeking. The context gave permission to seek help.

Has staff wellbeing truly become more commonplace, though? The pandemic has highlighted its need, but will the attention and support for it wane? It will be interesting to see what remains in place in organisations currently 'well resourced' for psychological staff support as we move further away from the peaks of the pandemic.

Further reasons for the changing profile of staff wellbeing include the (fair) concerns about the impact of any staff interventions. Some types of staff support work – for example, debriefs – have had a narrative about them causing harm. Even though this has now been found to be misguided, this has meant that psychologists offering support and healthcare staff seeking it have understandably kept away from them. Chapter 18, from Dr Sadie Thomas-Unsworth, myself, Dr Zoe Berger and Dr Joanna Farrington-Exley, explores the history of and evidence for psychological debriefs and present a model to deliver these in a psychologically safer way.

There can also be fears around creating 'bitching or moaning arenas' and/or uncovering problems or even causing trouble. Such concerns do need to be considered and signify the importance of working systemically and setting up the work well. In chapter 3, 'Setting up Systems of Staff Support Using a Systemic Approach', Neil Rees and I argue that thinking about positioning and commissioning of staff support work is central to setting it up. We chart how we applied systemic principles in building a comprehensive system to support the healthcare workforce in our organisation and argue that collaboration and developing relationships with key players is paramount.

To chronicle and celebrate

One of the main reasons for there being little published about psychological staff support is that many psychologists are doing this work but barely have the time to do so, let alone write about it. This book aims to redress this balance: to chronicle and celebrate the excellent thinking and practice that is out there already and to spur practitioners on to develop this field.

- Read the complete chapters and find out more about this book.

• Dr Harriet Conniff is Lead Clinical Psychologist for Staff Support, Evelina London Children's Hospital and Women's services, and part of the Senior Staff Psychology Team working across Guys & St Thomas' NHS Foundation Trust (GSTT)

References and further reading

Ahsan, S. (2022). 'EDI': endless distraction and inaction. The Psychologist, April 2022, Vol. 35, pp. 23–26.

Aris, S., Garraway, H., & Gilbert, H. (2021). Mental Health, Spirituality and Wellbeing. Hove: Pavilion.

Campbell, D. (2000). The socially constructed organization. London: Karnac Books. (The systemic thinking and practice series – work with organizations).

Clarke, R. (2017). Your life in my hands: A Junior Doctor's story. London: Metro Books.

Clarke, R. (2019). Medicine for the soul – Thoughts from dotMD conference 2019. BMJ blog. 

Collins, A. (2022). More than 7k resignations every month as NHS staff seek better work-life balance. HSJ. 

Department of Health. (2021). The NHS constitution for England. 

Dollard, M., & Bakker, A. B. (2010). Psychosocial safety climate as a precursor to conducive work environments, psychological health problems, and employee engagement. Journal of Occupational & Organizational Psychology, 83, 579–599.

D'Urso, A., O'Curry, S., Mitchell, L., et al. (2019). Staff matter too: Pilot staff support intervention to reduce stress and burn-out on a neonatal intensive care unit. Archives of Disease in Child Fetal Neonatal Edition, May; p.104.

Gawande, A. (2014). Being mortal: Medicine and what matters in the end. London: Profile Books.

Gawande, A. (2018). Why doctors hate their computers. The New Yorker, November 12th Issue.

Global Forum. (2019). 1.5-day workshop for global healthcare leaders called 'a systems-approach to alleviating work-induced stress and improving health, well-being, and resilience of health professionals within and beyond education'.

Kalanithi, P. (2016). When breath becomes air. London: Bodley Head.

Kurtz, A. (2020). How to run reflective practice groups: A guide for Healthcare professionals. London: Routledge.

Macaulay, C., & Conniff, H. (2020). Developing a programme of staff support in a children's hospital. Archives of Disease in Childhood British Medical Journal, June, 106(6), pp. 523-524.

Marmot, M. (2015). The health gap: The challenge of an unequal world. London: Bloomsbury.

Marsh, H. (2014). Do no harm: Stories of life, death and brain surgery. London: Weidenfeld & Nicolson.

Mildenhall, J. (2021). Paramedics lived experiences of post incident traumatic distress and psychosocial support. In: Murray, E. & Brown, J. (Eds.), The mental health and wellbeing of healthcare practitioners: Research and practice. London: Wiley Blackwell. 54-72.

Murray, E., & Brown, J. (2021). The mental health and wellbeing of healthcare practitioners: Research and practice. London: Wiley Blackwell.

Morrison, L. (2021). The wellbeing toolkit for doctors. London: Watkins.

Obholzer, A., & Roberts, V. Z. (1996). The unconscious at work: Individual and organizational stress in the human services. London: Routledge.

Olusoga, D. (2022). Much as we love the NHS we can no longer ignore the ethnic inequalities that beset it. The Observer, 47 (Accessed 20/02/2022).

Smith, J. (2021). Nurturing maternity staff: How to tackle trauma, stress and burnout to create a positive working culture in the NHS. London: Pinter & Martin.

Stoter, D. J. (1997). Staff support in healthcare. London: Blackwell.

Tavistock & Portman. (2019). Workplace stress and the supportive organisation: A framework for improvement through reflection curiosity and change. Health Education England Commissioned service from the Tavistock & Portman NHS Foundation Trust's National Workforce Skills Development Unit.

Wallbank, S. (2016). The restorative resilience model of supervision: A reader exploring resilience to workplace stress in health and social care professionals. Hove: Pavilion.

West, M. A. (2021). Compassionate leadership: sustaining wisdom, humanity and presence in health and social care. Swirling Leaf Press.

Wren, B. (2016). True tales of organisational life. London: Karnac.

Yong, E. (2021). Why health-care workers are quitting in droves. The Atlantic (Accessed 16/11/2021).