In Mindcast

Jane O’Rourke – Allowing And Letting Be Breath Meditation

Jane O’Rourke guides us through a breathing exercise to help us be with whatever difficulties we might be experiencing. Jane is a yoga and mindfulness teacher and a Psychodynamic Psychotherapist with children, young people, and families. She teaches yoga for trauma within the Trauma Service at the Tavistock and Portman NHS Foundation Trust.

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Hello, my name is Jane O’Rourke. I’m a Child, Adolescent and Family Psychotherapist, and I’m a yoga and mindfulness teacher. Today’s practice is about allowing and letting be.

We spend an awful lot of our time trying to resist anything that’s difficult that is going on inside our bodies, or any strong feelings or emotions, but today’s practice will help us discover what the benefits are about allowing and letting be whatever it is that we are feeling.

So coming to find a comfortable seat, it could be on a cushion or maybe in a chair, and if you are sitting in a chair then perhaps moving away from the back of the chair so you can sit nice and tall. So, finding an upright spine, but not too tense, and maybe allowing yourself the intentionality of being alert for the next few minutes, being alert to whatever it is that you might be feeling.

So first of all finding a steadiness of your feet on the floor, or maybe your bottom on the chair or on the cushion, so finding the solidity that’s there. And then bring your focus to the tip of your nose, where the breath is coming in and leaving. So breathing in and out through the nose, noticing the texture of the breath as it comes in. Perhaps a slight warming as it leaves the body, and having the focus here on the breath allows the mind to have a rest, so it can just settle, and all the while feeling the steadiness and connection to the ground.

So not trying to change the breath, just being present to it flowing in and out with a steadiness and ease. And then with some curiosity asking yourself where there might be some tension in your body. Notice what happens when you do that, there might be a little bit of resistance, if your back is aching a bit, or your shoulders, or your neck or wherever it may be. Just staying present to whatever the sensations are just for the next few moments…

How intense is the discomfort? Notice how your mind might race off and try and think about something else but just gently try and bring it back. And you might notice the intensity waxes and wanes, so it fluctuates and then with your next in breath take your breath to wherever the discomfort is, filling that area of discomfort with your in breath, and then with the out breath feel a releasing and letting go. And do this a few times, so it is bringing compassion and care to this area of your body that might be feeling discomfort, you might even like to visualise the breath as a colour going to that area of the body. And then notice how that part of the body is feeling now… and notice whether you are still feeling resistance to feeling the discomfort.

And then start to shift the focus again back to the breath at the tip of your nose, feeling the breath move in and out, at a nice, steady and regular pace. Feeling the connection to the floor… And perhaps extending your focus to a dual one of being present to the breath and also whatever it is that you might be feeling or thinking. Can everything be accommodated and accepted for how it is in this moment? And if it might feel a bit difficult perhaps stay with your presence of your feet on the floor, feeling the connectedness there with the steadiness of the earth. Noticing what is happening when you are not resisting and just being with whatever it is that might be difficult.

Just taking a few more gentle breaths here and then starting to wiggle the toes, perhaps softy reach the arms overhead and stretch, giving yourself time to come back into the room whenever you’re ready.

In Mindcast

Darren Ware – On Side As One

Darren Ware is the Community Equipment and Personal Protective Equipment Lead for the London Borough of Enfield. Darren speaks about the importance of a happy and confident workforce, team building and morale boosting in an ongoing crisis and saying thank you to the people who are not always seen but continue to work in the background making things happen.

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Hi and welcome. My name is Darren Ware, and I am currently the Community Equipment and PPE Lead for the London Borough of Enfield. I have decided to share some of my thoughts on a podcast with you all whilst we are going through this traumatic time with COVID-19. The title of my podcast is ‘On side, as one’. Well, what do I mean? With new times for us all and all our normal lives effected in ways that many have not been seen since the Second World War, much focus has been on the problem and not the solutions.

Physical issues caused by COVID-19 and mental health issues have been the biggest single worry for all of us and the health of our loved ones. Knowing we have and continue to prepare to guard against COVID-19 with the use of PPE, good house work, infection control is always, and always will be, in the forefront of everything that we do in ICES.

We have as a team incorporate laughter, thus creating a relaxed atmosphere, a fun environment ensuring all are working for the same goal, working as a family, and working as a unit, as ONE. It’s important we start each and every day the same, on a good foot. A collective chat, a drink in a relaxed environment, share a laugh a joke and discussion about anything from sport to politics, and of course the dreaded COVID-19 and how it has affected us all. Though we always reassure each other we are here to support, being prepared to be flexible, taking time to listen and not judge straight off the bat as we are all different.

We all have different worries in our lives, we spend though most of our lives at work and as such this needs to be a place that you feel happy and confident, and one where you can be relaxed and be yourself.

If one of us is down we rally around, some of us like space, some like an arm round us so to speak to help build us our happiness back up and our confidence. One of us may be tired, one of us may need a change in routine, they always say a change is as good as a rest so we like to mix the work up and ensure everyone is fresh and is encouraged to enjoy their work.

We have an open door policy, as in the sense that I’m here to listen, to help, to do what I can. I like to lead by example not afraid to go on to the van to deliver, to clean, and to collect items. There’s always a clear line that we do not cross and this results in respect and willingness to work by all us and more importantly, to work as a team.

A happy smile for our clients can make a massive difference, its important in social services that we radiate happiness to our clients, we are now more so then ever maybe the first face they have seen in a while, so we ensure we go the extra mile, we have that little chat, and if need be collect some milk or bread just to make sure that we are there to check on them and help them as best we can.

Each and every one of the Team in ICES is proud to make a difference in people’s lives and that is why we all enjoy working here.

We introduce fun and support for our network, always checking collectively and initially, for no one person can achieve all, there is no I in team. Positive mental attitude leads to dedication and in turn great results, we currently boast 100% KPI across the board on our on time deliveries. Why? Simply because we are a team and we work as one, pull as one and ensure we are both physically and as importantly our mentally health and have a framework within the team that can support each other whenever it is needed.

I’m proud to be part of the team and I am certainly proud to be its leader. It is important to thank the people who are not always seen here and that are in the background making things work and happen. We now find ourselves delivering in the region of 28,000 items of PPE daily and again it’s a challenge but one I am proud to say again that we have raised to and completed to high standard as we are on side and as one.

Thank you for listening to this podcast, I hope you have found this of interest, and do please leave any comments, thank you.

In Mindcast

Dez Holmes – Taking Care

Dez Holmes is the Director of Research in Practice. Dez reflects on self-care and resilience for colleagues working in children’s services and how paying attention to personal wellbeing is essential. Resources to support this are shared throughout.

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In this podcast I’m going to spend a bit of time reflecting on self-care and resilience. Not because I’m an expert on it, rather because I’m not very good at it to be honest. And evidence suggests it is something that social workers can sometimes struggle with. For colleagues working in children’s services (whose jobs are a thousand times more emotionally draining than mine, I should note), it is essential to pay attention to personal wellbeing.

Kanter said in 2007 that “While social workers focus daily on caring for others, issues of self-care are too often neglected”. I would add, taking care of our needs is something we must do not instead of supporting others, but partly because we want to support others to the best of our ability. Self-care is not a self-indulgent act, but rather it is an act of self-respect. In these times of high-emotion, when many of us feel very let down by those in power and distressed by the myriad structural inequalities in our society, taking care of ourselves so we can keep caring – and fighting – for others is an act of resistance.

As I come out of a slightly tough few weeks myself, one revelation is that the really basic stuff, the stuff that can sound trite when people advise you to do it, is actually really important.

Here are some very basic rules that sound obvious but bear repeating:

  • Eat something every day that is not beige. Dipping bread into anything runnier than bread whilst you hunch over your computer is not a meal. And Jaffa cakes are not one of our 5-a-day.
  • No matter how much coffee you drink, drink twice as much water.
  • Get dressed for work. Top and bottom half.
  • At the start of the day or week, identify which things on your list are absolutely essential – make these your priority and forgive yourself if you don’t get through everything else.
  • Do something that makes you out of breath every day, even if just for 10 mins. Shouting swear-words at the news doesn’t count, apparently.

Some other things that I’m finding helpful at the moment:

  • Treating my news intake in the same way I’m trying to think about my food. This means consuming less news, consuming it less often, and avoiding the junk. Scrolling through Twitter endlessly is the equivalent of grazing on pick & mix sweets – but some of the sweets are actually rusty nails.
  • Being thankful. I used to find those ‘gratitude diary’ things a bit cheesy. But I have been inspired by the wonderful Pooky Knightsmith, a mental health trainer and author, who logs ‘3 Good Things’ to take joy in every day, no matter how small. I’m still too self-conscious to tweet mine, but I have started writing them down every evening. It honestly makes a difference to my mindset.
  • Telling my colleagues how I’m feeling. This might feel a bit uncomfortable for those in a management role (perhaps we think we should show we are in control and don’t want to ‘overshare’?)… But I think part of respecting our team mates is letting them in on how I’m feeling – it means we can contextualise each other’s’ behaviour, support each other on an emotional level – and (importantly for me) it gives them permission to call me out when I’m being a grumpy so-and-so.
  • I’ve also been thinking about how not working together in a physical space means we might not be getting the daily ‘micro-affections’ that allow everything else to flow… that cheery wave in the car park, complimenting someone’s hair by the office kettle, sharing a joke before the meeting starts… all of these seemingly inconsequential interactions form a little ‘bounce mat’ on which the work stuff lands. Without these, we can fall into only interacting in a way that is entirely transactional. Making time to do the relational stuff can be the first thing to slip when we are stretched.

So, back to social work…

Harry Ferguson, in his excellent 2011 book ‘Child Protection Practice,’ notes that “Workers’ state of mind and the quality of attention they can give to children is directly related to the quality of support, care and attention they themselves receive from supervision, managers and peers…

This really highlights the important role of supervisors in this moment. My colleague Alison Domakin recently blogged about how practice supervisors have noticed that their primary focus in supervision has shifted to one of providing containment. For supervisors and managers maintaining (and strengthen) emotional connection, giving thanks, acknowledging effort and providing containment, all make a difference – and, crucially, supervisors and managers need these things too! For more on how organisations can behave to support practitioners’ resilience, do check out the SWORD project we’ve been doing (link in page notes).

There is also something about knowing when to be vulnerable – articulated beautifully in a blog by Camden social work manager Kim Christodoulou. She talks about ‘Acknowledging the pain of isolation and harnessing inner strength…being present, actively listening and acknowledging what we do not know. Through this, she says “I have come to know the people I work with more profoundly despite the isolation. It has been painful and real. I have learnt that we can feel connected despite the separation and that we can draw resilience from being vulnerable and being present.”

For me, something that grounds me when I feel a bit overwhelmed is noticing the positives: stories from SWs and families have given me a much needed sense of hope in recent months…

Practice supervisors have described to us how some practitioners are finding it easier to build relationships with children, young people and their families. Something about the experience of COVID-19 (perhaps a blurring of rigid personal and professional demarcations when we are ‘all in this together’) seems to have allowed a more relational approach to practice to bloom. 

Similarly, my colleague Susannah Bowyer together with Prof Brigid Featherstone  held a series of seminars with child & family social workers to explore what impact Covid is having on practice. They found that the overriding theme was of people experiencing potential arising from shifts in practice. 

  • Some children in foster care saying they feel ‘more in control’
  • Some families describing a sense of levelling between social workers, children, families and carers.
  • Some foster carers and practitioners finding the increased levels of trust more ‘empowering’.
  • Some managers noticing that an opportunity is emerging to rethink the purpose of social work practice altogether…

None of this is to suggest that things aren’t worrying, difficult and sometimes scary. They are to me. And I’m not suggesting for a moment that swapping your jaffa cake for an actual orange will fix the feelings of stress or existential dread. But being hopeful helps us to cope, and makes us more able to help others to feel hopeful. As the very wise Professor Louise Grant often says in her work on resilience “Please put on your own oxygen mask before assisting others”.


Ferguson H. (2011), Child Protection Practice, Basingstoke, Palgrave Macmillan

Kanter, J. Compassion Fatigue and Secondary Traumatization: A Second Look. Clin Soc Work J 35, 289–293 (2007). https://doi.org/10.1007/s10615-007-0125-1


In Mindcast


To celebrate the 72nd anniversary of the NHS on 5th July 2020, leaders from across North Central London have come together to share key moments from the past few months, as a way of saying thank you. Our speakers are:

  • Michelle Johnson, Chief Nurse and Director of Patient Experience at Whittington Health NHS Trust
  • Jo Sauvage, GP City Road Medical Centre and Chair at North Central London CCG
  • Kay Matthews, Executive Director of Quality at North Central London CCG
  • Siobhan Harrington, Chief Executive at Whittington Health NHS Trust
  • Caroline Clarke, Group Chief Executive at the Royal Free London NHS Foundation Trust
  • Paul Jenkins, Chief Executive at the Tavistock and Portman NHS Foundation Trust

Please use #ThankYouTogether to share your experiences in celebration of the NHS.

View transcript

Gratitude is a funny thing – sometimes we are only able to feel grateful for something when it has gone, or is at risk. Sometimes it can be hard to express because it means really acknowledging our dependence on somebody or something. But gratitude also comes out at times of celebration and the marking of life over time – birthdays, anniversaries, key moments and memories.

The NHS, on which we all depend, and to which many of us contribute, has an anniversary on Sunday July 5th, marking the 72 years since this extraordinary collaborative system of care for others was put into motion. There’s  no doubt that the global pandemic has raised the profile and the nature of our dependence on the NHS in  a profound and powerful way – and the individual as well as the organisational challenges that we have faced in Covid, and continue to face in sustaining life and development within  the NHS.

We also know that at times of enormous systemic strain, simple but authentic connections with others are key. So we thought it would be a good way to mark the anniversary by asking some system leaders in North Central London to share key moments from the past few months, as a way of saying thank you. You’ll  hear from nurse leader from the Whittington, leaders from Primary Care and from the NCL CCG, and  CEO’s from  Acute Services and  Mental Health – and from all of them you will hear about a specific interaction or memory from these turbulent months as a way of saying a thank you that recognises what the NHS means to us all as individuals as well as a community.

– – –

Hello, my name is Michelle. I’m so incredibly proud to be a nurse in the NHS and to have led our organisation through the acute phase of the COVID-19 pandemic. I am equally, if not more so, incredibly proud and in awe of our staff over this period. There are so many stand out moments that I would like to talk of, but one really does stand out to me.

It was at the height of the peak with our hospital and community health services caring for a high number of patients with COVID infections. I went to one of the acute assessment wards where we were caring for high dependency patients and I met two staff – one newly qualified nurse and one healthcare support worker. They were both wearing full PPE, which they did for the 12 hour shift, and working in a bay with some very sick patients.

We shared a moment of reflection on their experience, the incredible sadness of patients who had deteriorated and died. They were devastated. We also then shared a happier moment of how their ward team had all worked together so well and the camaraderie was fantastic and got them through the dark days. We also laughed which was so lovely, their spirit and resilience was wonderful. Thank you.

– – –

Hello, my name is Jo Sauvage. The last few months have been really hard work for everyone. What has made me really proud to be in my role is the fact that across our system we’ve worked hard together. We’ve tried to connect with each other and we’ve shown care for each other. I cannot count the number of emails I’ve received that start “how are you? I hope you’re well” and end “stay well, stay safe”.

We’ve remind ourselves and each other of the importance of thinking about each other and caring for each other as people. This has made me proud to be who I am, where I am, at this moment – the fact that we have remembered to treat each other well.

– – –

I’m Kay and I’m the Executive Director of Quality for NCL CCG. There were many moments I witnessed during the COVID pandemic that made me feel unbelievably proud to work for the NHS and to work with the most amazing group of people. But there were nine outstanding days that really stood out for me

This was when the Quality team came together to provide Infection Prevention and Control training for over 200 care homes in North Central London. It was at the peak of the pandemic and this group of heroes worked night and day, weekday, weekends including the bank holiday and did the impossible.

They negotiated the release of 17 nurses from different organisations, trained two super trainers and 15 train the trainers and just did the most amazing job of speaking to all of the 218 care homes often 3 or 4 times until they got through to the right person who realised how much they needed this support.

They didn’t give up. They really knew how much care homes needed this and they needed it now. And most importantly their key single unrelenting focus was to make sure everyone who needed it, got it – and I know this had an impact on patients’ lives.

I am so proud of what they did, how they did it and what they achieved. Thank you.

– – –

Hello, my name is Siobhan, I’m Chief Executive of Whittington Health. One moment that actually sticks with me most among many times is when I was in the queue at a lunchtime with our 2m distancing and I was chatting to one of our speech and language therapists (SALT) from the community, who actually had been redeployed to the ITU unit. Firstly, I was struck physically talking to her, she had marks from her face mask where she had just come off ITU for a break. I recall her telling me about her skin and I then followed up finding some face cream which could be given to staff in ITU, which was donated to us, which was really, really great.

She talked to me about what was really happening for her, and her family, and in her life, and in her working life. She talked about how at the beginning she wasn’t sure as a SALT she could or would be able to be helpful in ITU and that actually she that her skills were really quickly transferable, especially some of the analytical skills that you use within SALT and how that helped her with the observations in ITU.

She also had a young family so she was obviously worried about taking the virus home. She told me how she had decided to sleep in a different room from her husband, from her kids, and how hard that had been for all of them as a family. She also really spoke about how excited she was to care for people in ITU and how professionally she really did relish her new role, even though she was pretty tired. I suppose what I would really like to say is, thank you.

– – –

My name is Caroline Clarke, I’m the Group Chief Executive at the Royal Free London. it seems like ages ago that we started treating patients with the COVID virus, in fact it was back in February, and as we mark the NHS 72nd birthday it’s a chance to pause and reflect on how the last few months have been.

I remember very early on, early one morning, meeting a senior doctor in the car park who told me that she had just sent her kids away, to Scotland, where they would be safe and she wasn’t sure when she would see them again. And then later that day, talking about hotels and where our staff were going to be so that they could shield their families, and thinking through what a massive sacrifice that was.

Then of course seeing people cheer themselves up on social media with songs and Tik-Tok dances, and thinking what amazingly resilient people we have, as well as people who are willing to give and sacrifice. And then hearing from colleagues who would do all that, and then go home and look after vulnerable members of their community, and make sure that they were safe.

It just makes you realise what an amazing group of people you are who work in the NHS – kind, caring, and just the very best. So, I just want to say, thank you.

– – –

Hello, my name is Paul Jenkins and I’m the Chief Executive of the Tavistock and Portman NHS Foundation Trust. This Sunday 5th July marks the 72nd anniversary of the NHS, one of the country’s best loved and most important institutions. The last couple of months have provided a significant test of our resilience and ability to deliver, probably of the kind that few of us have seen in our working careers. It is a test that I think we have responded to brilliantly.

At the heart of that has been the efforts of all of our staff, working well beyond the call of duty, to meet the needs of patients. By staff, I very much mean all staff. One of the best things about the last couple of months is how the profile of different groups of staff has been increased – both the contributions of frontline staff but also those who provided support in IT, in catering, in cleaning, and in back-office functions.

We’ve also had a time where people have had to undergo a lot of personal challenges, working incredibly hard, but also those who have experienced bereavements or who have even seen the loss of colleagues. There is no doubt that COVID is not yet off the scene.

Our commitment as leaders in NCL has to be that we continue to put staff wellbeing right at the centre of our focus and ensure we provide the support to staff to get through the challenges of the months ahead. Thank you very much.

– – –

So, as part of our celebration for the 72nd birthday of the NHS on Sunday, this is our #ThankYouTogether, from Together in Mind.

In Mindcast

Dominic O’Ryan – Substance Use

Dominic O’Ryan qualified as a Clinical Psychologist from UCL in 2000. He is the Lead Psychologist in Substance Misuse Services and the CBT Training Lead for Camden and Islington NHS Foundation Trust. Dominic speaks about the use of substances during this time.

View transcript

Hello, my name is Dominic O’Ryan and I am the Lead Psychologist for Substance Misuse Services in Camden and Islington NHS Foundation Trust.

I am going to talk about something that many of us might be facing.

During these strange times it is very common to find we have increased our use of substances.

By substances, I mean different types of stimulants, depressants, cannabinoids, psychedelics and opioids; substances like nicotine, caffeine, alcohol, sleeping tablets and strong pain killers.

And we do these things often because substances help us make the best at the good times – they help us to celebrate, they help us to mark occasions, whether that is a large event or simply making it through the week or the day.

We use substances to make something better of the difficult times as well – we use them to commiserate – we use them to switch off and unwind and sleep – to get rid of difficult thoughts, feelings and body sensations.

And we can use substances because they are a way of connecting with people, they become integral to our social network, we drink when a friend is drinking; we have our next cigarette often because our smoking buddy is smoking.

And there isn’t anything necessarily problematic about this. It may be fine.

Substance use becomes more problematic when it feels like we don’t have any other way of doing those things – we lose sight of other ways of celebrating or switching off or connecting with people.

And when we disregard the risks associated with the substance use it can transform itself into substance misuse.

This is something that can happen slowly over years but at confusing and stressful times, it can very quickly sneak up on us, catching us unaware.

And so it is important to realise that often these using behaviours are happening in autopilot.

And then to spend some time reflecting on why we are using substances and what thoughts and feelings, and body sensations are present as part of our urge to pick up a drink or to have a smoke or sniff.

Stepping out of autopilot is a very particular and also learnable skill of gentle, curious and compassionate self-observation.

We need to reflect on what the function might be of our use the substances – what might we be avoiding or trying to achieve.

What is it that is so tricky about these tricky thoughts, feelings and body sensations that we would rather do something potentially harmful in the long term than experience them in the here and now?

Having noticed and become aware of these things, are we ready to be open to these tricky experiences, to unhook from stories that maybe we have fused with, stories that tell us the experience is unbearable, or that we are not able to manage?

We can unstick and de-fuse from these stories sometimes just by naming them – “there’s that old story about failing playing again”, “I’ve tuned in to Radio Idiot again.”

Maybe we can sometimes be truly courageous and thank our minds for nudging us. “Thank you mind for reminding me that I need to unwind tonight.”

And then, at the choice point, when we have given ourselves space to decide rather than to act on autopilot, have we identified alternative workable actions that can help us with our short-term goals and connected them to longer term important personal goals and values?

So when next you need to celebrate, switch off or connect, give yourself permission to pause, step out of autopilot, become aware of your internal and external experience, be open to tricky thoughts, feeling and body sensations and make a more active, sustainable choice in the direction of your long term wellbeing.

In Mindcast

Jane O’Rourke – 7 Minute Grounded Breathing Meditation

Jane O’Rourke guides us through a breathing meditation that connects us with the earth to help us feel resourced and steady. Jane is a yoga and meditation teacher and a Psychodynamic Psychotherapist with children, young people, and families. She teaches yoga for trauma within the Trauma Service at the Tavistock and Portman NHS Foundation Trust.

View transcript

Hello, my name is Jane O’Rourke. I’m a Child, Adolescent and Family Psychotherapist, and I’m a yoga and mindfulness teacher, and today we are going to be doing a grounding exercise.

So if you can find a position sitting down on the floor, or perhaps in your garden or in the park and find a comfortable posture. So, allowing the spine to be nice and tall, and the shoulders sliding down the back. Then I invite you to put your right hand connected to the floor, to the earth, and the left hand over your heart. In this position you can get a sense of the right hand touching the earth and the left hand in touch with yourself and how you are feeling in this moment.

So feeling the steadiness of the earth underneath your right hand and the qualities of the earth that is there, the steadiness, the resilience of the earth… and that is a resource for us, to help us feel steady and calm, and resilient as well. And sensing the breath underneath your fingertips over your heart… and we might need the steadiness of the earth underneath our right hand to feel a steadiness so that we can make an enquiry about how we are feeling. What is your left hand over your heart telling you about how you’re feeling in this moment? There is nothing that you shouldn’t be feeling, it is opening up to whatever it is that is here in this moment. So it is cultivating a curiosity about what is going on at the moment. And if you feel any tension arising, connect with the steadiness of the earth under your right hand as you feel this breath of life moving through your body. And this left hand over your heart is also a gesture of self-compassion, taking care of yourself, connecting in…

And now start to sense the breath through the tip of your nose, meanwhile the right hand is connected to the floor and the earth below. As you breathe in, through the nose and out through the nose… noticing the pause on the in breath and the out breath, and maybe a slight warming of the breath as it leaves the body… Our breath is our lifelong companion, it is with us from the day we are born until the day we leave this earth. So sensing the breath is being a companion in this moment, as you feel a sense of steadiness and calm that is connected to the earth… and your presence in this moment… and if you notice your mind has wandered off just gently bring it back to the focus of the breath at the tip of the nose….

So just taking a few more breaths here before moving out into your daily activities asking yourself what you most need to help in the day ahead… Perhaps it is a sense of connecting in, all this steadiness that is always there. Perhaps just taking a moment just to notice a few more breaths and if the day feels a little overwhelming giving yourself some time and attention.

And then whenever you are ready coming back into the room in your own time.

In Mindcast

Rachel Surtees – Fear In The Time Of Coronavirus

Rachel Surtees is the Director of Strategy and Transformation at the Tavistock and Portman NHS Foundation Trust. Rachel powerfully describes the impact of fear in the experience of a family being forced to really face the reality of the serious illness that Covid-19 is.

View transcript

A couple of Sundays ago my 7 year old was acting out of sorts. Nothing dramatic – just a bit more clingy than usual, picking fights with his brother, getting upset over things he’d normally brush off. 

I’d taken the week that should have been half-term off as annual leave, to try to keep some sense of normality going, and so I was a bit irritated that the last day of our time off together had been a bit bad tempered, but didn’t think too much more about it.

Then 10 minutes after going to bed, he called me back into the room. He told me between sobs that he was worrying, that he felt like he had something in his throat and that he was choking. And suddenly we were back in April. Back to the three bleak weeks when as a household we staged our own battle against Covid.

His tears were an abrupt reminder of the long tail of fear.

My husband and I were both unwell with the virus at the same time. We avoided hospital admission, though arguably, maybe shouldn’t have done. Family and friends brought us daily care drops and checked in on us, but of course couldn’t come in to distract the kids. Our youngest knew that things weren’t right, but wasn’t going to question the chance to watch Paw Patrol for 8 hours a day whilst chomping down beans on toast. Our 7 year old however, understood that the seriousness of the situation. The daily bombardment of news was unavoidable. Reports of the growing death toll, of the emerging evidence that men (my husband) and people from BAME backgrounds (me) were at higher risk of dying seeped into the house despite our best efforts to cocoon ourselves. And although he didn’t ‘get’ all of it, he got enough and became increasingly anxious. It didn’t immediately stop when we recovered, and for a few weeks after, me going into work was a worry for him, and Sunday evenings were a particular trigger.

And so on that Sunday evening came the dawning realisation that his fear hadn’t gone. He’d got used to managing it well enough that he’d stopped talking about it, but my week off from work was enough of a disruption to his new routine, that suddenly the fear was prominent in his mind again.

I don’t think he is alone in that. Coronavirus is a fear inducing disease. Just the phrase ‘global pandemic’ is enough to make your heart skip a beat, and not in a good way. Enough time has passed since the start of the outbreak that the fear might not be as acute and visible as at the beginning, but it hasn’t gone away, we’ve just got used to it.

We are not all scared. But some of us have been, and some of us still are. And that’s ok. Lots of people who I talk to are scared for others rather than themselves, and at times that creates a new set of dilemmas between your responsibility to your employers or patients, and your responsibility to loved ones.

There is a risk that in our rush to make things normal, and ok again, that we inadvertently end up pathologising fear. That we talk about it as sign that something is wrong. When arguably, being scared of the thing that at the time of recording has killed nearly half a million people around the world, seems like a pretty normal reaction to me. 

There have been many comparisons made to the war and military. We talk about going to battle, about the frontline, about command structures and being deployed into units or teams. Having Covid, to me, felt like being invaded. But for all of the accuracies of the parallel, and I realise I’m stating the obvious here, health and social care staff aren’t soldiers. The experience of working in an environment that carries a high level of personal risk, the realities of losing colleagues who you may have worked alongside for years, is new. Very new, and it requires an adjustment.

Whether we like it or not, and whether we are individually experiencing it or not, fear (our own, our families’, our colleagues’, patients’) is now a much more frequent feature of our working lives. The challenge is how we are able to acknowledge this whilst still getting on with the job. 

When the first wave of lockdown restrictions were lifted, sections of the media ran with a narrative that the government messaging had been too effective and that people would need to be forced back out into public spaces. The sunny weather and bank holiday weekends proved them to be very wrong. But behind the narrative was an undercurrent that people’s fear was somehow silly or unfounded, and worse, that it was being used as an excuse to shirk responsibility. I’ve heard similar conversations played out across workplaces up and down the country in recent weeks.

Now more than ever, when we’re tired and stretched, we need to be kind to each other. To work harder to understand different perspectives. To notice when a colleague might be struggling and need a hand. To create a culture in our teams where fear isn’t treated by default as a sign of illness or weakness, but that can be openly acknowledged without judgement.

In Mindcast

Sarah Appleton – The rise of “Moral Injury” in NHS workers

Dr Sarah Appleton is a Clinical Psychologist working in Employee Health for Central London Community Healthcare NHS Foundation Trust. Sarah raises our awareness of the concept of “moral injury”, and how to support staff to effectively prepare for, identify, and manage potentially morally injurious events.

Sarah references the recent paper titled “COVID-19 and experiences of moral injury in front-line key workers” authored by Williamson, Murphy and Greenberg (2020).

View transcript

We find ourselves in a time of great uncertainty where, amidst significant change to most areas of our lives, we continue to experience considerable change to our job roles and responsibilities.

Throughout my conversations with staff members, and mirroring my own personal experience, I have been struck by the range and intensity of emotions evoked by this change of role. Staff members have shown great strength in speaking about their experience of difficult feelings such as stress and anxiety, particularly in relation to a high clinical demand in the context of limited resources, or to a change of role prompting feelings of uncertainty or inadequacy. Staff members have also shown great strength in speaking about difficult feelings such as guilt that may arise due to their clinical load being reduced, or to feeling as if they “should be doing more”.

Across each of these challenging situations there lies a common theme; staff members are experiencing a jarring between their values (i.e. the care that they feel they should, or they want, to provide) and the care that they are practically able to deliver.

I therefore wanted to write a blog with this in mind. To raise awareness of the concept of “moral injury”, and to support staff to effectively prepare for, identify and manage potentially morally injurious events (PMIEs).

The following content is a summary of a recent paper titled “COVID-19 and experiences of moral injury in front-line key workers” authored by Williamson, Murphy and Greenberg (2020). I’ve attached the paper to this podcast and would definitely recommend giving it a read. Whilst I’ve focused predominately on understanding what moral injury is, and how to best manage this in NHS settings, they also provide really helpful recommendations for clinicians working with moral injury presentation.

What is a Moral Injury?

Moral injury is defined as the profound psychological distress which results from actions, or the lack of them, which violate one’s moral or ethical code.

Morally injurious events can include acts of perpetration (i.e. situations where we feel we have actively done something that goes against our moral code), omission (i.e. situations where we feel we have not helped in the way our moral code dictates) or experiences of betrayal typically from leaders or trusted others (i.e. situations where we feel that others have not treated us in the way that we would treat them).

When we experience a moral injury we might feel overwhelmed by difficult thoughts such as “I’m an awful person” or “my colleagues don’t care about me” and difficult feelings such as guilt, shame or disgust. Whilst moral injury is, in itself, not classed as a mental illness, we see how these experiences may contribute to the development of other mental health problems such as depression, anxiety or post-traumatic stress disorder.

NHS staff members will encounter PMIEs on a daily basis; redeployment may mean that clients we used to treat are without their usual care, a higher clinical load may mean that we have less time to spend with a seriously ill patient, or a lack of resources or training may mean that we do not feel that our own health and wellbeing is being properly considered by those who are supposed to protect us.

Research shows that a number of factors may also exacerbate these existing challenges, possibly increasing the likelihood of developing a moral injury. Potential risk factors for moral injury may include situations where; a vulnerable person has died, staff members do not feel adequately supported, staff members do not feel prepared for the emotional/psychological consequences of decisions, staff members experience a PMIE in addition to other traumatic events (e.g. loss of a loved one), or there is a lack of social support.

It is important to note that not everyone who encounters a PMIE will experience a moral injury. However, raising awareness of PMIEs allows us to better understand and effectively attend to an often misunderstood or neglected distress response (both in ourselves and others).

Supporting NHS Workers Exposed to PMIEs

Williamson, Murphy and Greenberg (2020) outline five practical recommendations to support staff experiencing potentially morally injurious events. These include:

  1. Raise Awareness: Staff should be made aware of the possibility of PMIE exposure in their role, and the emotions, thoughts and behaviours that might be experienced as a result. Frank discussion of this topic in advance, most probably facilitated by supervisory level leaders, may help develop psychological preparedness and allow staff to understand some inevitable symptoms of distress.
  2. Establish Support: Staff should be encouraged to seek informal support, from trained peer supporters, managers, colleagues, chaplains or other welfare provision, early on and take a ‘nip it in the bud’ approach—rather than dwelling on the PMIEs they have been exposed to. There is good evidence that social support is generally protective for mental health.
  3. Seek Professional Support Where Appropriate: If informal support does not help, professional help should be sought early on. Professional support is likely to be needed when difficulties relating to the PMIE become persistent and impair an individual’s daily functioning.
  4. Proactively “Check-In” with Staff Wellbeing: Those in leadership roles should be encouraged to proactively ‘check-in’ with their teams, offer empathetic support and encourage help-seeking where necessary.
  5. Ongoing Monitoring:  Organisations should actively monitor staff exposed to PMIEs, facilitate effective team cohesion and make informal, as well as professional, sources of support readily available. Please note the psychological debriefing techniques or screening approaches are often ineffective.

So that is just a brief overview of moral injury and some of the ways we can manage that within an NHS setting. I would definitely recommend giving the paper a read just to get a bit more in depth explanation on that as well if you are interested. Thank you.

In Mindcast

Sarah Carney – Emotional Strength in a Time of Uncertainty

Sarah Carney is an Independence & Well Being Service Manager in Enfield. She shares her experience of supporting a Care Home at the onset of a pandemic and the need for emotional strength during a time of uncertainty.

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In the early hours, half asleep, I received a call to say one of our residents had died of Covid in hospital. I could feel the sadness over coming me, that feeling in your throat. I got dressed and left.

At this time, my colleague and I were supporting a residential nursing home as an interim, due to the manager being unwell at the start of Covid lockdown.   

As services we are now supporting people in different ways and we have different systems in place.

Infection control, PPE, social distancing is all the current trend at work and at home.

Driving to work on that day, brought a different feeling, I didn’t have concerns about being late or I need to finish a piece of work but an anxious feeling in my stomach, my mouth was dry, different thoughts went through my head, sadness for the person who had died other families who will be fearing the same for their loved ones, how do we support families, what if staff don’t turn up for work because of their fear of Covid or have family member affected by this, the questions, thoughts continued for the rest of the drive.

Now when I look back on this drive, I realise this was just anxiety getting the better of me.

All the policies and procedures can be followed but what no one really knew, was the impact of the emotional trauma that this would have, on all of us.  

This was going to pull upon every bit of my experience and knowledge and the skills I had learnt over the years, I also knew I was going to work along side a great colleague who also had years of experience, and was very knowledgeable.

Working together, we will get through this. This became my inner voice.

I walked through the residential doors, with confidence, “Morning” I said. I was greeted with, “Morning” – but there was a “but, we have no staff, no nurse on site, staff worried about Covid being in our care home, is it true someone has died of Covid?”

I have always been honest with staff and at this time, it was important that staff knew that we had sadly lost someone in hospital with Covid but the reception area of a residential home was not the place to discuss it, so with a deep breath, calm voice, I acknowledged the staff worries, explained we would have a meeting to update staff.

The next step was to look at ensuring our residents were safe.

By the early afternoon, my colleague and Ihad started to implement an action plan.

Our 4 priorities were:

  • Keeping our residents safe and well
  • Acknowledging family members anxieties and fear of their loved ones catching Covid and how we can support them in any way we can
  • Keeping our staff safe and well, supporting them through this crisis, listening to their concerns, fears and anxieties. Respecting their opinions and working together to find solutions.
  • Reflecting on the day. This could be anything, the pain of losing someone, what went well, what do we need to do differently.

Leading a team in the Covid 19 pandemic brought out an inner strength that I wasn’t aware of before.

My expectation of staff was high, things needed to change quickly and at times I found myself frustrated and annoyed, not with the staff but with the situation.

The expectations from staff, family members, commissioners, GP’s and others was sometimes over whelming, at times you just didn’t have the time to think but I had to keep calm, think through the priorities, even making a list, got me through these times.

Communication was vital – being seen and working alongside care staff enabled you to check in with staff on how they felt and share their experiences.

It was important that we supported and responded to our staff’s mental health needs. Staff needed to know that we cared and valued them.

Regular meetings, where staff could bring anything to the table, were listened to, respected, and difficult situations discussed in a sensitive way. We all reflected on the days together, the sadness, and keeping people well.

In Mindcast

Caroline Mayger – Managing an Adult Social Service Remotely: From The Outside In

Caroline Mayger is an Independence & Well Being Service Manager in Enfield. She shares how it feels to manage an adult social care service remotely by creating stability within care settings from a distance.

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Hello, my name is Caroline Mayger. I am a Service Manager for Independence and Wellbeing, front line social care services to vulnerable adults living in Enfield and this is my story:

I returned to the UK from India on March 16th, 2020 after 6 months of travelling.

What a return! No smooth entry but a large bump!

The world I found was upside-down chaotic, full of insecurities and fear – an unknown narrative and I realised India was about 3 weeks behind the curve. I went in to self-imposed 7- day isolation, a drift and struggling to make sense – It definitely wasn’t normal and I can remember thinking that if this was the new normal I didn’t like it!

Reflecting now on my return to the UK I can see that it took me time to find some rhythm to my day get up, shower, get dressed, breakfast, emails, Zoom, lunch, day time TV, watch a film, yoga…anything to get me through the day.

Once I managed that I felt a little better and I was reframing my day to day life as information came through. I still felt very unsettled but was becoming adjusted to my new normal.

I returned to work on the 4th April 2020. From the outset I was remotely working – that took some getting used to – no existing workload, no face to face contact and Covid-19 causing chaos, upset and fear. I felt impotent – it was like being in a vacuum.

Lockdown was in place and our frontline staff remained in work looking after vulnerable people – the first cases of Covid were present in services. I remember one early managers’ meeting – I was present but not.  As a remote worker I felt guilty at not being with colleagues in work.

I felt a clear resonance with the time I spent at home – insecurity, the need for routine, searching and shifting for information that ‘felt’ real. We needed a clear pragmatic approach for our staff and managers – to provide reassurance and to navigate the risks. I found myself a new role – coordinating clear information, structure and an evidence-based approach to supporting services, leaving colleagues to focus on the front line, manage the risks, support staff.   

My role was an outside-in view of what was happening and in response to an ever-changing landscape. This was a whole team effort with everyone playing a part to create an environment where we could deliver services.

Gaining staff trust was paramount – it was and is a new environment for us all – If the staff felt like I did – what did we as an organisation need to do to get through this? At the time it was about survival and trying to find a way through, to take staff with us and to reduce the risk and get the job done. 

In terms of leadership, during this time we took a directive approach to provide a structure for people to work within whilst also being very supportive to individual and team needs when required – providing people space to question and communicate with us – our approach has been by being consistent, sharing information – we listened flexed and responded – sometimes hour by hour.

Feedback from staff is that this was appreciated, and our care staff continued to provide services during the biggest challenge we have ever had despite their own anxieties.

My emotional intelligence has been at full stretch – especially as a remote worker – picking up on issues through tone and nuance – checking in with people, offering time to just listen. On a day to day basis and from a distance communication was key – ensuring information was valid and fact based. This was especially difficult in the first two or three weeks when the information was changing, being updated and we had to respond daily to review the guidance and practice – on a personal level I was anxious that we were doing enough – was it correct? Were we creating risk? I had to trust in our approach – open communication, respond when required, be transparent, listen.

We were often reactive to the changing landscape and ensuring these messages were communicated effectively to staff. I think that the one thing that worked for us was that we were very open about not having all the answers, we couldn’t eliminate risk completely but based on best available advice this was the approach we were taking. We did not waiver from that stance and it stood us in good stead.

During this crisis our staff and our managers have stepped up and provided the stability needed to provide safe and responsive services.

I hope that from a distance I have been in some way able to provide the framework for those on the front line to focus on their work and to stay safe.

We are not at the end of this journey yet – We need to continue to provide consistent leadership – to be clear, to listen, to communicate and to be available – this will support our staff in the best way possible and enable them carry on caring. I am very proud to be part of these Teams. Thank you for listening.