Working NEAR the brink

As psychological professionals, we are all too familiar with burnout – estimated to account for 37 per cent of all work-related cases of ill-health and 45 per cent of all working days lost, costing the NHS £2.4 billion a year. This data pre-dates the pandemic (Agha, 2018), and may well be an underestimate. Others had already identified an upward trend in NHS staff reporting having felt unwell due to work-related stress, and in those leaving their NHS post due to poor work-life balance (Johnson et al., 2017).

In Psychological Wellbeing Practitioners (PWPs) like myself, working in the NHS Talking Therapies for Anxiety and Depression programme (previously known as Improving Access to Psychological Therapies), prevalence of burnout has been found as high as 69 per cent (Westwood et al., 2017). It is no wonder that a recent government review from the House of Commons Health and Social Care Committee cited workforce burnout as one of the key challenges facing the IAPT programme today.

What does this challenge look like, in daily working life? The following account has been anonymised to protect the identity of the service and individuals involved.

"In early February 2022, we received a mass email from service leaders stating that we were not on track to meet the monthly target for triage assessments. They stated this was due to too many staff taking leave over half term and being on sick leave. The email went on to tell us we would be required to offer 1-2 additional triage assessments per week throughout the month to ensure the services' targets were met, and to discuss any concerns with our Line Managers.

Later that day, an informal discussion with my PWP colleagues highlighted the email had provoked shared feelings of stress, frustration, and dread. One of my colleagues became tearful, sharing she was already too overwhelmed by the current workplans. Someone else stated they were going to ignore the request entirely and expressed anger towards managers for not acknowledging the pressure we were already under. Another simply said they were too drained to think about it today. Over the next few weeks, the stress and low morale was tangible, with more colleagues taking sickness leave throughout the month. And while we should have felt relieved when the month was up, instead we all shared a sense of defeat that this would happen all over again at Easter."

Many people seem to think this type of burnout is inevitable for PWPs, due to the growing demands on services, increasingly ambitious targets, and lack of resource to meet them. But I will argue that it is possible to mitigate without costing any time or money, by shifting towards a culture of compassion within leadership.

The compassionate leader

In their 2019 book, Stephen Trzeciak and Anthony Mazzarelli coined the term 'compassionomics' when their review of hundreds of papers provided evidence that compassion not only improves outcomes for patients, but also the financial health of organisations and wellbeing of staff. So how does a compassionate leader behave?

The consensus conceptualises it as a four-part process (Atkins & Parker, 2012), characterised by the acronym 'NEAR':

1. Noticing: Being present with and focusing on the joy and suffering of others, coined by Kline as 'listening with fascination' (Kline, 2002; West, 2021; Worline & Dutton, 2017);
2. Empathising: Mirroring and feeling others' emotions, both positive and negative, without being overwhelmed and therefore paralysed to help (West & Chowla, 2017);
3. Appraising: Taking the time to suitably explore the circumstances of suffering to better understand them (Gallo, 2017);
4. Responding: Taking thoughtful, timely, and intelligent action to mitigate suffering of individuals and the team (Worline & Dutton, 2017; McCauley & Fick-Cooper, 2020).

Let's return to the example I shared. Did it reflect compassionate leadership?

Firstly, I would argue that the biggest failure from leaders in this case was the choice to communicate via a mass email. Clear, open communicating through dialogue facilitates compassion within leadership (West, 2021). While the choice by leaders to communicate via email was certainly the most efficient means of sharing information within a large team, this speaks to a culture of closed communication, which immediately stifled the opportunity for leaders to notice and therefore empathise with the suffering of the workforce. And, while it could be argued that the leaders were attempting to appraise and respond to their concerns by advising PWPs to discuss concerns with their Line Managers, this was perceived by the workforce as performative – likely due to the inaccessibility of the leaders who were enforcing the change, and the perceived lack of time they took to communicate to the staff. Effective compassionate leadership requires leading by example, so how can IAPT leaders expect their staff to increase their workload if they are unable to take the time to make this request in person?

One of the biggest pitfalls of communicating via email, as highlighted in this case, is that it prevented the opportunity for leaders to be present with and listen to their staff. Indeed, careful listening is often considered to be the most important skill of any effective leader due to its associations with higher employee engagement, organisation performance, and trust (Men & Stacks, 2014; Ruck et al., 2017; Kluger & Itzchakov, 2022). Had leaders instead chosen to communicate with PWPs through a face-to-face medium (e.g. team-meetings, group supervision), this may have facilitated engagement in the NEAR process and the negative consequences associated with increased workloads could have been mitigated (McCormack et al., 2018; Vivolo, 2022; Turnpenny, 2017; Koomson et al., 2020; Hodkinson et al., 2022).

For instance, leaders would have been able to influence how their message was received by the workforce through non-verbal means of communication (e.g. tone of voice, body language, facial expressions), which have been shown to play a significant role in establishing a positive work environment (Kurniadi et al., 2021). They would have been better able to notice the response of the PWP workforce and to better understand and empathise with the weight this request held for some of the staff, by mirroring and feeling the emotions the PWPs shared. Had any PWPs provided verbal feedback at this time, leaders would have been able to notice the suffering of the PWPs by listening carefully, without judgement or evaluation, to both the content of their concerns as well as the feelings that they expressed in response to the request (Passmore, 2022). This is known as active listening, an interpersonal skill which is used by PWPs to support understanding and empathy for their patients.

Face-to-face dialogue would have also supported the effective appraisal of concerns, particularly when leaders actively listen to the response from targeted questions such as, 'Do you have any concerns about this change?' or 'What support do you need from us to implement this change?' (Cardon et al., 2019). This would also have enabled leaders to better understand the PWPs suffering and therefore offer a genuine attempt to respond effectively, examples of which could have included the opportunity to temporarily drop other clinical duties or committing to explore additional staff resource through the recruitment of temporary bank staff. Even if such actions were not possible, had leaders communicated an intention to find a way to respond to school-holiday-related staff shortages impacting upon targets in future, this could have mitigated the sense of defeat the PWPs shared once the month was up.

Working cultures

In the scenario, someone expressed anger towards the managers for not acknowledging existing pressures. Instead, leaders appeared to be imposing their understanding of the situation, namely the difficulties meeting targets due to staff sickness and annual leave. IAPT practitioners are required to submit leave requests a minimum of six weeks in advance, and it is normal for such requests to increase during school holidays. Should the service have been prepared for the shortage? Certainly the hints of a culture of blame is likely to inhibit compassion and prevent learning from experience (Edmondson & Zhike, 2014).

Conversely, cultures of open communication involve encouraging team members to share their experience through dialogue. This creates psychologically safe working environments, whereby leaders help hold emotional burdens, thus freeing up their staff capacity for other tasks. Considerable research demonstrates that such teams are both more productive and innovate, with one meta-analysis of 49 studies suggesting productivity increases by 35-40 per cent (Tannenbaum & Cerasoli, 2013; West & Markiewicz, 2016).

This suggests that had leaders taken the time to openly communicate with the workforce, they may in fact have created time in the service overall, by building resilience to withstand the increased workload. Factors such as persistent high workloads are often outside of IAPT leaders' control: but what they can do is mitigate burnout by facilitating psychologically safe working environments that prioritise the wellbeing of staff (Bailey & West, 2022).

Towards the antidote

I do not believe leaders in IAPT ever intend to behave without compassion. So, what may be getting in their way?

Many factors influence a person's capacity to demonstrate compassion within healthcare, including poor working conditions, poor leadership, role conflicts, and excessive workload (Gilbert, 2017). As many IAPT leaders are practicing clinicians themselves, it is likely they too were experiencing burnout and therefore lacked the emotional capacity to lead their teams with compassion. Empathising requires leaders to feel the emotions of others without being overwhelmed and therefore too paralysed to help. Emotional exhaustion, depersonalisation, and compassion fatigue are all associated with burnout  (Salvagioni, 2017).

Let's consider that capacity more. Many organisations now recognise that burdens of excessive data reporting and misaligned policies undermine compassionate leadership (see the NHS National Quality Board Shared Commitment to Quality). In a target-driven climate, perhaps the IAPT model is simply incompatible with compassion. Despite 'staff wellbeing charters' (the New Savoy Partnership), perhaps it is in danger of becoming a victim of its own success.

Certainly, the future of IAPT is closely tied to the wellbeing and satisfaction of PWPs. Compassionate leadership must therefore be at the heart of national efforts to nurture cultures of open communication, in turn enabling high-quality, continually improving, and compassionate care. We need a commitment to compassionate culture throughout all levels of the organisation (system leaders, policymakers, organisation and team leaders, and individuals) in order to avoid performative demonstrations of compassionate leadership (Evans, 2022).

Only time will tell whether compassion could be the much-needed antidote to burnout cultures. But I do have hope that isn't the challenging shift some may argue it is. As Trzeciak and Mazzarelli put it, 'You can go through your daily activities with brusque efficiency and let people know how busy you are, or you can go through your day valuing human connection and showing compassion… and it actually doesn't take any longer.'

• Kat Wheatley is a Psychological Wellbeing Practitioner currently supporting the DETERMIND project at the Brighton & Sussex Medical School

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