This long read from Royal College of Psychiatrists includes guidance about how to support organisational wellbeing during the pandemic. It outlines what can help the organisation to maintain healthy functioning during the crisis, how to optimise organisational wellbeing, and expands on the guidelines that relate to the individual, team and organisational levels in more depth.
The wellbeing of an organisation is a prerequisite for the wellbeing of staff. Mental Health Trusts are currently working under extraordinary conditions and under great strain. In these circumstances, maintaining the health and functioning of the organisation is crucial to support the wellbeing of staff and their ability to operate.
Unique features of the challenges raised by the Covid-19 pandemic for Mental Health Trusts include:
- An unprecedented situation for which there is no blueprint or recent experience to draw upon
- New risks to physical health, threats to survival and encounters with death leading to levels of fear and anxiety which challenge the ability to think
- The fear of becoming a vector for infection and endangering patients, colleagues and family, which further isolates staff from usual sources of support
- High rates of staff sickness, leading to gaps in service provision and to staff redeployment in unfamiliar acute services
- Fear and anxiety in patients, which can create additional management challenges.
Part 1: what can help the organisation to maintain healthy functioning during the crisis?
Principles drawn from organisational consultancy models can support Mental Health Trusts during times of crisis. There are also many current examples of excellent organisational functioning that we can learn from. This paper aims to support all staff within a Mental Health Trust to consider the processes which contribute to the wellbeing and functioning of the organisation.
The primary task of a Mental Health Trust is to provide compassionate, effective and safe care to patients. During ordinary times the frontline staff are supported in their work by a range of activities which help them to process information, share experiences and dilemmas, and provide a containing framework for anxiety within the multilayered structure of the organisation. This structure enables staff to carry out their specific tasks without becoming overwhelmed. The senior management structure provides the conditions required for staff to carry out their work, manages the interface with the necessary external stakeholders and leads the organisation.
The Coronavirus pandemic changes and challenges the primary task, adding the need to keep staff and patients protected from infection and to provide physical health in addition to mental health care. There is little respite for staff or possibility to alleviate anxiety when away from work and the organisation is potentially flooded with raw states of anxiety. Patients are made unavoidably aware of the anxiety and physical vulnerability of staff, and this raises valid anxieties about the ability of professionals to contain and to care for them. The uncertainty, lack of control and deluge of information about the global situation, including the deaths of health care workers, further increase emotional distress and states of fear and threat. Staff are being redeployed and working in unfamiliar roles without the support of their usual colleagues. The need to help organisations and staff to manage anxiety has rarely been more evident.
The containing function of the organisation is crucial at this time and it is also challenged by heightened levels of fear and threat. The organisation needs to be able to respond and to adapt to the crisis whilst providing as much consistency and stability as possible. Excessive levels of fear and threat can lead to a fight-flight response with anxiety becoming the driving force, decisions made in a reactive manner, and the ability to think and to tolerate uncertainty severely compromised.
This document outlines key ideas and measures intended to support the organisation during the current crisis.
The first part of this paper highlights the key points to consider while the second part expands the key points further. The guidance below is applicable at the individual, team and organisational levels.
Guidance to optimise organisational wellbeing during the COVID-19 pandemic
Recognise that the excessive anxiety affects functioning and the ability to think at every level of the organisation.
Be aware that urges to take immediate action may be a response to anxiety.
Maintain usual activities and avoid service closures where possible to maximise the stability of the organisation. This includes educational activities continued in adapted form.
Aim to establish a culture of learning from experience when things go wrong and avoid blame. It is an unfolding process and decisions will be made which will need revision.
Develop opportunities for thinking about clinical dilemmas and the emotional impact of the work building upon existing supervision, peer support, reflective practice and team meetings throughout the organisation.
Use the channels of communication between frontline staff and senior management to demonstrate how management decisions are directly informed by the positive and negative experiences of staff. Avoid actions and communications which may increase feelings of helplessness and loss of control in staff.
Maintain differentiation of staff roles as much as possible and avoid terms such as “non- essential duties” which can demoralise staff. All staff have valuable expertise and experience to make a helpful contribution at different stages of the crisis.
Explicitly recognise staff at greater risk and take into account their specific needs.
Ensure that redeployment is based upon a realistic appraisal of the task and that it matches with staff skill sets. Address any gaps in experience by providing training.
Encourage all staff to be mindful of their own internal states, fear and threat trigger reactions based upon previous experiences of trauma and loss. Recognise that all staff will have vulnerabilities and blind spots which affect their functioning at work and offer support.
Be kind to one another. Functioning during a crisis calls for unity. Increased stress will hit upon pre-existing tensions in any organisation. Pre-existing dilemmas can be addressed once the crisis is over.
Start preparing for recovery now if possible, as it will require opportunities for staff to process their experiences at work once the pandemic is over.
Part 2: expanded information from the guidelines
Personal and organisational defence
The pandemic causes a level of understandable anxiety in everyone. The organisation needs to support staff to tolerate the discomfort of this without becoming overwhelmed or overly defended against their vulnerability and fears. This supports staff to function, to think under pressure and to develop creative solutions to dilemmas.
Common organisational defences include omnipotence and denial of vulnerability with the risk of disregard for the guidelines and a potential increased risk of becoming unwell. The organisation needs staff to act in keeping with the reality of their potential vulnerability. Excessive anxiety might also lead staff to avoid risky situations and to subsequent feelings of guilt and shame. Teams and colleagues need to support each other to ensure that individuals do not stretch beyond what is safe for them, mentally and physically, or become overly avoidant. For instance, some organisations have introduced specific measures such as buddying schemes and staff huddles which help to create a culture in which staff vulnerability and distress are expected, normalised and openly addressed.
Powerful forces of denial and splitting are also likely to become even more activated during a crisis. A culture which seeks to openly understand the reality of the conditions under which some teams are working is vital for staff to feel heard and understood.
The open recognition of difficult realities can help staff to recover their own sense of agency and to suggest possible solutions. For example, a psychiatrist remembered that there were surgical scrubs in the ECT suite once the organisation acknowledged the lack of personal protective equipment.
The importance of teams
Belonging to a team enables peer support, social contact, and agreement about the task and shared principles of working, including clinical and ethical dilemma. As staff become unwell, new teams are being rapidly created and, in some cases, staff have to learn new skills. Mental health professionals are required to provide intimate physical care for patients which may evoke complex emotions such as inadequacy disgust, guilt and shame. The loss of contact with familiar colleagues means that staff are likely to feel more alone while performing those new tasks.
In order to help the newly configured staff groups to feel they belong to a team, various activities can be implemented including the usual team meetings, supervisory structures and reflective practice. These activities will support the development of a containing structure for the team even if there is a turnover of its membership and encourage the formation of new peer relationships. Many organisations are already adopting helpful new models of working, establishing and supporting morale in their newly developed teams.
To relieve anxieties due to the redeployment of staff, the organisation should carry a realistic appraisal of staff skillsets, experiences and aptitudes. There needs to be an explicit explanation of the reasons behind requests, a clear description of new roles and reassurance that induction and training will be provided. Staff should also be redeployed on a voluntary basis as much as possible to encourage a sense of control and agency.
Differentiation of staff roles
The functioning of an organisation can be to an extent compared to a living organism in which different organs or structures perform different functions. Changes in the functioning of one part of the system affects the whole, and the different parts are interdependent.
Mental Health Trusts incorporate clinical teams carrying out different tasks in providing care to a patient group with a wide range of needs. The current crisis introduces significant new risks to the physical and mental health of staff, which affect teams differently. Those risks must be explicitly acknowledged by the organisation and additional staff needs (such as transport, accommodation, meals at work etc). should be met.
Anxiety and other emotions permeate the whole staff group. Staff and teams less involved in frontline and acute work may feel guilty not to work in the clinical “hot spot” areas alongside their colleagues. This is understandable and important to articulate. All staff contributions are needed. In addition, it is crucial that staff do not take unnecessary risks and remain well to provide back-up to other staff and services.
Organisational activities which support the capacity to think and to process anxiety under pressure
The wellbeing of an organisation depends upon its ability to process high volumes of information and to address emotional strain and anxiety at all levels. Clinical issues in frontline staff are managed within the supervisory structures of clinical teams, while wider organisational issues and anxiety associated with them are held by the senior management. Excessive anxiety requiring further containment is escalated within this structure and returned in processed form as advice and guidance. These frameworks enable staff at every level to get on with their work without becoming overwhelmed or preoccupied by anxiety from other parts of the service.
Seniors managers also need support to manage anxiety, as it is crucial that anxiety from the higher levels of the organisation do not leak downwards and negatively impact upon the functioning of frontline staff. A nurse working in A&E for example will struggle to help their patients if they are anxious about the Trust’s financial position.
During a crisis, the usual containing structures within the organisational hierarchy should be maintained as much as possible at each level of the organisation through appropriate supervision, reflective practice and team meetings which might need to be provided remotely. More organisational resources are required to process and manage heightened levels of anxiety.
Activities need to have a clear structure and aim, and to be run by suitably trained and experienced staff. They also need to be offered on a consistent basis and for as long as the crisis continues as inconsistency and potential withdrawal of containing structures may increase anxiety within the organisation.
Without sufficient opportunities to reflect about the emotional impact of the crisis, the ability of the Mental Health Trust to process anxiety becomes compromised. Anxiety may then become a driving force within the organisation, decisions may be made reactively and in a knee-jerk manner, and frontline staff may have to manage anxiety that would usually be escalated to more senior levels of the organisation. If frontline staff are preoccupied with anxieties within the organisation, their ability to provide clinical care may be compromised and senior managers may not be able to provide much-needed leadership.
The example below illustrates how reflective practice can assist staff in recovering their connections to each other, to recognize their shared tasks and experiences, and recover their sense of agency and ability to contribute to decisions during the Covid crisis.
The weekly Balint group for core trainees was reinstated using a remote platform during week 2 of the lockdown period, after an initial cancellation of all meetings by the organisation. The group shared experiences of fear and threat at work which developed into criticisms of the senior managers for handing down “diktats” which felt out of touch with their needs- which included basic requirements such as food to be delivered to staff working long shifts on wards with unwell patients with Covid-19. The facilitator commented it seemed they were looking to the management to know just what was required and seemed to feel themselves in a rather helpless and stuck position, after which the group started to recover their more usual functioning, remembered they could feed back to the senior management through previously established channels and started to draw up a short list of suggestions to help them to be better provided for during their shifts.
The Role of leadership and authority
The role of the senior staff and leadership team is crucial to the containing capacity and healthy functioning of the organisation, and this role is even more important during a time of increased threat. Managers have a key role to play in modeling a culture of learning from experience and avoiding blaming. Healthy organisational functioning is based on the expectations that things may go wrong especially during a crisis. The health of the organisation is defined by its attitude and response to it, and its ability to openly and non- judgmentally seek to understand and to learn from these events. The idea of a culture of benign enquiry helpfully supports these processes.
New channels of communication between senior managers and frontline staff are being developed during the crisis. These can helpfully demonstrate that the organisation is genuinely interested in areas of difficulty at the frontline and responsive to them. A perceived lack of communication and understanding may amplify anxiety and develop into an unhelpful cycle in which staff feel increasingly alienated from the management.
When anxiety is excessive and not contained within the team, it can lead to increased projection of some aspects of team functioning into the management. Staff may then look to the management for directions and solutions and lose their own sense of agency and capacity to make decisions in their own area of work. Unrealistic expectations may be placed upon the managers and division may be created within the organisation. Regular and consistent forums for staff to communicate and to share dilemmas and for their recommendations to be part of decision making by the organisation mitigates against these processes.
Maximising the stability of the organisation
Maintaining usual activities helps the organisation to remain steady as much as possible. However, some of those activities may increase pressure upon staff who are already overstretched. Mandatory training reminders, continuing professional development targets and appraisal processes for example can add to the sense of persecution and anxiety.
Closure or suspension of services require careful consideration as it may lead to further destabilisation and convey a sense of crisis and additional loss for patients and staff. It is important to avoid more drastic measures than needed, as such decisions affect the wider community of patients and people supporting them, including primary care. Terms such as “non-essential” are best avoided as these can create splits and have long-term deleterious effects on how those teams are regarded by the organisation. Psychological therapy services may be helpful to the organisation in times of crisis as part of the support and containment to staff and teams.
Education and Learning during and after the crisis
This is a time-limited crisis and activities to support staff training and learning convey a containing sense that the organisation is able to see beyond the crisis, recognising the ongoing need for staff training and offering ‘business as usual” where possible. There may also be enhanced opportunities during the crisis for learning if offered as part of creative and adaptive discussion as the situation develops.
Although continuing professional development is important for all staff, trainees and junior staff may be particularly vulnerable to anxiety during the Covid crisis. Their work may feel connected to a particular team and their on-call duties carry unpredictable risk of exposure to the virus, making supervision essential. Teaching and Balint groups have an important function beyond the educational one in allowing junior staff to come together as a group, to share experiences and to support one another. Those groups should be operated virtually using e-mail, phone, Skype etc. The ongoing provision of these activities, in adapted ways, also demonstrates that their consultants and other seniors are continuing to function and not overwhelmed, which provides further containment.
Triggers and Blind Spots
An extraordinary stressor such as the current global pandemic will stress the organisation at the points of pre-existing vulnerability and expose pre-existing tensions. It is important to recognise that all individuals and teams have their own experiences of loss, anxiety and trauma. This means that the current circumstances may trigger reactions or touch upon blind spots linked to past experiences, increasing distress and anxiety. No staff are immune from this and it is to be expected. In a triggered state of mind, fear and panic may replace thinking and a sense of perspective is lost. Staff and teams can be helped to recognise when this happens through encouragement to monitor their own internal states and to look out for each other to mitigate its effects on wellbeing and functioning at work.
Recovery and Repair
Once the pandemic is over, the organisation will need to prioritise recovery for all staff by providing opportunities to process their experiences at work. Negotiating with teams about what they would find helpful and respecting staff’s own ways to manage is important. If not addressed, challenging and traumatic experiences in teams are likely to continue to exert influence within the organisation.
Experiences at work during the pandemic are likely to profoundly change staff relationship with the organisation. Many have been required to work in an environment which has become a potential danger for their physical and psychological health. Staff may have lost family members, colleagues and friends, the mourning extends more widely even than this and includes the loss of the workplace as able to protect and adequately provide for patients and staff.
The organisation can help with these important processes of adjustment and loss. Explicit recognition and understanding are a first step towards repairing the relationship between staff and their workplace. Staff can be helped to move out of a potential position of blaming and possible grievance if the experiences can be shared and shortcomings recognised. The organisation as a whole is subject to levels of fear, threat and lack of clear guidance. The reality that no-one anticipated or expected these events or had all the answers can be faced. There will need to be space for understanding, forgiveness and repair to prevent ongoing grievances with inhibit psychological recovery.
The aim of recovery can be to achieve a realistic and shared view of a workplace in which all staff were placed under great strain and tried their best under extraordinary circumstances. Shortfalls and mistakes made along the way would need to be openly addressed and learned from; and will assist process of coming to terms with events and mourning what has been lost.
Recovery may also involve recognition of new learning, creativity and ways of working that will have emerged as part of the organisation’s response. The organisation will have to learn about itself to continue to develop as an adaptive and responsive institution. Staff will have acquired new skills, teams will have worked cooperatively across the usual boundaries, new channels of communication will have been established, with red tape cut on occasions. In addition to the difficulties, we will notice productive and heartening examples of joint endeavours, with and increased bonds within the organisation and new ways of working which will be important to retain.
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