Carol Menashy

I'd like to share with you how SISOS is supporting staff at The Royal Free Trust during the coronavirus pandemic. Today I was both humbled and deeply moved. The Royal Free Trust (RFT) continue to take the health and well-being of it's staff seriously. I’m proud to say I’m one of them. In response to COVID-19, a multidisciplinary group have been tasked to specifically look at how staff can be supported through the pandemic. It recognises that the support will need to be multi-faceted and my role as the founder of SISOS (Safety Incident Supporting Our Staff) and present SISOS lead will be to help provide emotional peer-led support for our staff alongside chaplaincy and varied mental health professionals. Released from my clinical role (scrub nurse) for the foreseeable future, I will be able to focus on, and will endeavour to promote and support, the emotional safety of my colleagues Trust wide. The mental health first aid training I undertook in preparation for my SISOS role will surely be put to the test. None of us know what obstacles and challenges we will have to face, both in our private and professional lives, as we race off track, gathering speed and moving towards an unknown destination. By and large, I envisage the peer support SISOS provides will be achieved remotely: telephone, WhatsApp, Facetime, text, emails. The experience we have gained allows us some insight into how this support will be received and I feel positive. Who could possibly have predicted two years ago when SISOS first evolved the events of the last few weeks. Implementing, embedding and sustaining a peer support initiative has thrown up many challenges but we are reassured that our colleagues can be confident of genuine emotional support from peers who are guided and supported by professionals within a Trust which cares. SISOS: caring is our passion Human being is our highest banding Read my other blogs on the SISOS journey: Part one Part two Part three Part four

As I mentioned in my previous blog (part 3), the number of staff using the SISOS calm zone as a safe space to take time out was surprising because of the sheer volume and also the average time it was used for (15 minutes). Certain factors contribute to the  success of a safe space: management buy-in, location and, to a degree, ambiance. At Chase Farm Hospital, we have been fully supported locally and at a trust level. However, in any organisation there will always be people who are averse to change.  In this blog I will share with you some of the negative experiences I encountered, because anyone thinking of setting up a similar initiative needs to be aware that it is not always plain sailing and unfortunately not everyone sees the need to support staff. I will also share with you how SISOS is evolving to meet our staff's needs. On a couple of occasions when myself or other key listeners have been in the process of supporting staff in the SISOS calm zone, there has been a knock on the door. This knock speaks far louder than you or I ever could. The knock in it’s intensity says, "I disapprove". These occasions are rare but they do happen. One comment I overheard was, "if you can’t take the heat you shouldn’t be here". My answer to this attitude is onwards and upwards. The location of the room is in it’s favour because it isn’t isolated and is easily accessible without the need to change into or out of scrubs. This makes it available to other departments and also to the support staff, such as chaplaincy who visit us fairly frequently when we request. This clearly has had a positive effect on take-up. The room itself is simply furnished and is in sharp contrast to the clinical environment. A small windowless store room, triangular in shape, has been transformed into a sanctuary of calm and psychological safety. The makeover consisted of a woodland scene wall mural, a Himalayan salt lamp, a reclining chair, a small side table, a coffee table and two regular chairs. I’m frequently asked, "Can we use the calm zone as a prayer room?" The answer is yes, because we must aim to support staff in their working environment and, provided one group or another doesn’t claim the room as their own, then why not? None of us can know what someone else’s journey has been like. When we put on our shoes and leave our homes to come to work we also put on our professional fronts often masking our private lives. This became very apparent to me in the first week and is shaping how the framework for SISOS is evolving and the breadth of support we are now providing. Originally set up to provide emotional support for staff centrally or peripherally involved in safety incidents, we recognised that these incidents are fortunately rare. However, you don’t need to be involved in an incident to be affected emotionally and most of our take-up is supporting staff for none-incident related events. We had one such event recently that affected a large number of our staff because of the circumstances and the age of the patient. Following this event, myself and another 'key listener' were relieved of our clinical duties and we were able to provide emotional support over a couple of days. This put our model to the test and I'm pleased to say it passed. These are work-related events. The other side to take-up involves staff who are distressed because of none-work related issues. We deal with this by signposting staff to other support structures, such as our Employees Assistance programme and our mental health First Aiders Hub. What we discovered was staff were not prepared to accept SISOS simply as a support for ‘second victims’. They demonstrated a need for other kinds of support, such as domestic abuse, money worries, bullying, and they wanted support for these issues. They weren’t prepared to differentiate. We have developed other pathways to support staff holistically. Staff come to us at a rate of approximately three per week (theatre department) requesting a ‘SISOS’ – meaning, I need to talk, and that can be on any topic. The anonymity SISOS provides, because of the confidentiality and trust, is impacting favourably and staff are opening up. Patients too. Our badge wearing listeners have attracted the attention of several patients who have felt safe enough to open up about domestic abuse. The SISOS team have supported three such patients and have taken advantage of that small window of opportunity to hopefully help them to change their lives for the better. SISOS is now part of a broader staff support model at Chase Farm Hospital and we are working on various new arms for it, including a student nurse support arm. This happened directly as a result of a student nurse needing support out of university hours after witnessing a distressing event. Read the other blogs in my series Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital: Part two Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part three: the SISOS calm space Safety Incident Supporting Our Staff (SISOS): The journey part 5. A celebration If you are thinking about setting up a similar initiative in your trust, I would be happy to discuss SISOS further with you. Contact: [email protected]

In this third blog of the series, I will discuss how I went about setting up a calm space as part of Chase Farm Hospital's Safety Incident Supporting Our Staff (SISOS) initiative. This allows staff to go and rest and get support if needed. As a second victim, on reflection, the two things I recognised that I had needed were peer support and a safe psychological space. A place where I could have been supported and my dignity protected. Over the years I’ve seen too many of my colleagues breaking down in the tea room, hiding in the sluice, or crying in the toilets. This is not acceptable. The NHS Constitution Key principal three states: "Respect, dignity, compassion and care should be at the core of how patients and staff are treated not only because that is the right thing to do but because patient safety, experience and outcomes are all improved when staff are valued, empowered and supported". Health Education England are now talking about safe spaces and psychological support. Our SISOS Calm Zone has been the most amazing achievement. Since the provision of our safe space, our staff talk about feeling valued. A member of staff who might have previously gone home because they had a headache, rest in this safe space and often are able to return to work safely within the shift. I talked about setting up a safe space where staff could go and rest and be support if needed and was promised that when we moved to our new hospital building a room would be provided. For the first six months SISOS functioned without a dedicated safe space in our old building and I faced the same old challenges that I’d faced as a member of the bullying and harassment support team many years ago. One of my roles then was to support staff who alleged bullying and the biggest challenge I always faced when I received a call was finding a suitable place to provide support. So often the support I gave was negatively impacted by an inadequate space. So I was very disappointed to find every door in our new department had a label on it and not one said SISOS Calm Zone. This was a challenge and I approached my manager and asked nicely but directly: "Where is the room I was promised?" "You’ll need to speak to orthopaedics," came the reply and so I did. "We have a lot of equipment", said the orthopaedic sister. "What’s more important, your crates or our staff?" I said. My words didn’t fall on deaf ears and our fabulous staff helped to clear the storeroom, relocate stock and also get rid of stuff we hadn’t used for years. The room is small, triangular in shape and windowless but the location is perfect. Safety is paramount and the room is located next to the tea room and so isn’t isolated and is easily accessible without the need to wear scrubs. This is important for staff who need support but also for anyone coming in to support staff such as chaplaincy, who frequently come up to support our staff when requested. Once we had the room I panicked a little realising that we would need to furnish it. I wrote to several charities, one of which was the Louise Tebboth Organisation. I was seeking confirmation that I was on the right track. This wonderful organisation not only supported our initiative but donated generously towards the purchase of a reclining chair. Realising that I wasn’t able to personally receive funds, I contacted our Royal Free Charity who took up the reins. They guided us and provided further funding for a woodland scene wall mural, a side table and a Himalayan Salt lamp. These simple furnishings have transformed the store room into a sanctuary of peace. My next fear was, "What if no one uses the room?" So I put in a wooden money box with bingo counters and a short note asking people to place a counter into the box if they had used the room and felt that they had benefited from it. I wanted to maintain confidentiality but needed to know numbers. We have eight theatres in our department and in the first week I counted 52 counters, the second week 56 counters. I carried on counting for a couple of months and the lowest count was 38. We knew for certain that the room was being used and it was being used appropriately and with respect. One consultant I work with classes himself as a SISOS frequent flier. He has a ten minute power nap during his shift. So the room isn’t only used to support second victims, fortunately that isn’t needed very often, but on a daily basis staff can zone out when they need to with or without support. We would highly recommend a safe space but if your department cannot provide any such space then look to see where a room might be found in another area that you can use to support staff. It is about planning and even if no room is available anywhere think about how you could set up a temporary safe space if needed. Read the other blogs in my series Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital: Part two Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part four: Take up Safety Incident Supporting Our Staff (SISOS): The journey part 5. A celebration

My previous blog talked about how the idea for SISOS (Safety Incident Supporting Our Staff) – an initiative to support staff involved in safety incidents – came about at Chase Farm Hospital. The SISOS team provide confidential, emotional support in a safe environment and make other support, including professional help more easily accessible. It is important to recognise that we are 'Listeners' and not professional counsellors. My second blog continues this journey. A flower does not think of competing with the flower next to it. It just blooms. (Zenkei Shibayama) My original presentation of SISOS to the department where I work (theatres) had a huge impact and colleagues recognised the need for it and wanted it. Strong leadership and commitment is essential. I have faced challenges along the way and so far have managed to keep going, but it hasn’t always been easy. I will talk about those challenges as I go. There have been times when I have questioned why I’ve kept going and every so often that question is answered. At a recent conference where I presented a poster, a beautiful human being, kind, intelligent, dedicated to saving lives, looked me in the eyes and said, "How do you support second victims?" and then proceeded to weep uncontrollably. Needless to say I took their willing hand and we shared tea together in a quiet spot. Their incident happened 4 years ago and no blame was attached. This beautiful human being was not an F1 but a consultant. Ironically two days later at work, a consultant suggested that consultants as a group don’t need support because "We have years of experience, we can manage". It’s fair to say that as a group, experienced consultants have challenged the need for this initiative more than other groups and some have been very cynical. However on the whole they have been supportive and welcoming of it. Following my original presentation and the positive feedback from my colleagues, the first thing I did was to form a working group of very senior staff. Nothing would have been possible without their belief and their buy-in. We examined our Trust policy and looked at existing resources; for example, we have an Employee Assistance Programme, which provides professional counselling free of charge to our staff. It was important to see what we as an organisation could provide without incurring additional cost. My experience has been that although support is there in theory, in reality staff were not necessarily accessing it and so one of our roles as Listeners is to improve accessibility. As a group we looked at safety, including the safety of our Listeners and how we support them. Guidelines were produced and training provided. We recognise that we are not experts and that this is still a relatively new initiative for us and one which is evolving. Read the other blogs in my series Safety Incident Supporting Our Staff (SISOS): A second victim support initiative at Chase Farm Hospital Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part three: the SISOS calm space Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part four: Take up Safety Incident Supporting Our Staff (SISOS): The journey part 5. A celebration For further information please contact me: [email protected]

Suicide rates for doctors, nurses and allied healthcare workers are rising and being involved in a safety incident increases this risk. The need to support staff when things go wrong is evident. We come to work to do the very best we can for our patients, often ignoring and at the cost of our own health. Most adverse incidents happen, not because we are bad at what we do, but because of system failure. As professionals who care passionately about our work, we blame ourselves when things go wrong. Albert Wu (2000) recognised this phenomenon and coined the term second victim. In this series of blogs I will share my own experiences of setting up and developing Safety Incident Supporting Our Staff (SISOS). In this first blog I explain the catalyst that led to developing SISOS. The Journey In the changing rooms where I worked as a scrub nurse, I overheard a group of nurses discussing the distressed state of a young doctor. There had been a never event in their theatre that day and the young doctor was the operating surgeon. Moved to tears I wanted to go and put my arms around that doctor but I didn’t feel that I had ‘permission’. ‘It was none of my business, what if I made things worse?’ So I dumped my scrub suit into the laundry bin, put my theatre shoes away and went home. I’m a theatre nurse but more importantly I’m a mother, the mother of a young doctor and that night fearful for the surgeon’s safety I was unable to rest. If it was my daughter I would have wanted someone to be there for her. Galvanised by a mother’s strength, I vowed that nothing could or would hold me back and so the next morning I wasted no time in knocking on my matron’s door. "I was worried about that young doctor last night", I said. "So was I", said my matron. "I rang her and she’s coping’". I was relieved to hear this but as I turned away I realised that there was an urgent need for timely, accessible structured support for when things go wrong. I reflected on an incident that had happened to me and I asked myself this question: What would have helped me, at one o’clock in the morning, all those years ago, when I sat alone in a hospital tea room: devastated, anxious, ashamed, guilty, having flashbacks and feeling like the worst nurse on the planet? I had let my patient down. Two things came out of those reflections. Firstly, I had craved the companionship and compassion of my colleagues because I knew that they above all people would get it. They would understand how this situation could possibly have arisen without attaching blame. Secondly I recognised the need for a safe space, a place where my dignity could have been protected and I could have shared this experience in privacy. As far as I was concerned, my name was in neon lights, I was the failed nurse, there to be gawped at. These two experiences, the young doctor’s and my own were the catalyst for SISOS. Safety Incident Supporting Our Staff. Chase Farm Hospital now has 24-hour support for staff affected by adverse events. The model which I’ve developed is known as the 365 second victim support model and sets out a framework to provide support at various levels from trained peers through to professional help. The care which we can now give our second victims is compassionate, non- judgmental and happens in a dedicated safe space, where experiences are shared in confidence. Empathy, respect and compassion assist in emotional healing. Following a successful audit I’m delighted to say that this model is now being rolled out Trust wide. My passion is that all of our colleagues deserve access to this kind of care. I recognise that it won’t be easy but I will not be deterred, will you? Read the other blogs in my series Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital: Part two Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part three: the SISOS calm space Safety Incident Supporting Our Staff (SISOS) at Chase Farm Hospital. Part four: Take up Safety Incident Supporting Our Staff (SISOS): The journey part 5. A celebration For further information please contact me: [email protected] Further reading: Hirschinge, LE et al. Clinician Support: Five Years of Lessons Learned. Patient Safety & Quality Healthcare. March/April 2015. Willis D, et al. Lessons for leadership and culture when doctors become second victims: a systematic literature review. BMJ Leader 2019;1–11.

This initiative at Chase Farm Hopsital, from the Royal Free NHS Foundation Trust, was started to mitigate wrong implant never events. Instead of just the one person going into the stock room to collect the implant and equipment, two people go and both check. This poster is a gentle reminder to check with a colleague before sending to theatre. What do other Trusts do to mitigate this type of never event?

Waste in the operating theatre costs money and is harmful to the environment. Reducing waste in the NHS is paramount if we want to reduce costs and help save the planet! This initiative was set up by theatre nurse, Carol Menashy, Chase Farm Hospital, the Royal Free NHS Foundation Trust. It is a fun game to get staff in the operating theatre to really think about cost and wastage within theatres. While playing the game – Twist and Shout, by the Beatles is played. Attached are some fun exercises with shopping lists for various procedures where teams vie to get the closest estimate to the actual cost. Worked out by senior staff. Nearest team wins a box of toffees. Also, we do a cost awareness exercise audit fun day. Monthly audit of the cost buster bin where out of date items or items opened in error is audited monthly to see how much we are wasting and aiming to improve. The bin is placed inside the stock room. Here are some template questions you could use or make up your own depending on what surgeries you undertake. I'd love to hear from anyone who tries it out or from anyone who has similar initiatives.