Eve Mitchell

Over the last couple of weeks I have been engaging in one of my favourite pastimes – chatting. I realise this seems a little frivolous, but after the more formal ‘meetings’ of previous weeks, chatting seemed appropriate. There is a serious reason behind this, the impact of ‘emotional labour’. Emotional labour is defined as “having to induce or suppress feeling in order to sustain the outward countenance that produces the proper state of mind in others”.[1] Or, in layman’s terms, pretending you are OK. For my colleagues and clients across health and social care, and particularly for frontline nursing and care staff, there has been an even greater need to deliver compassionate patient care whilst managing their own emotions during the pandemic, and somehow with the easing of lockdown some of the façade has started to fail. Through conversation, it has become clear that there is a new impact of COVID-19 on the mental health and wellbeing of healthcare staff: absorbing the anger of the public, patients, and their carers. In a previous post I mentioned that there was fear from some colleagues about potential litigation once the pandemic was over. Looking for someone to blame for what was and was not done. This is not an unusual reaction, but showering staff with vitriol does seem a little unprecedented. For example, in the care homes I work with every home has received letters or complaints about the care of their residents from family members: "you did not care for my mother"; "you let my father die alone"; "my mother died of loneliness as you wouldn’t let me see her"; "it is down to your lack of care that my brother died"; whether the home had COVID infections or not. The upset this has caused is palpable, with exhausted staff bearing the brunt for doing their job in the most difficult of circumstances. A similar story is heard from GP practice nurses and reception staff – patients refusing to wear masks, accusing the nurses and doctors of wilfully letting them suffer and refusing to see them when they were in need, demanding to see a professional immediately, refusing to leave the premises. A massive change for the surgeries who earlier were being given gifts of cake and chocolate and sent messages of gratitude. Hospital staff seem to have faired better, although as outpatient appointments come back online there is an expectation that the pent-up fear and frustration will be released in this setting too. Maybe it is not only health and care staff who suffer from compassion fatigue – it has happened to the general public at the same time as the clapping stopped and the next normal dawned. However, it is not clear how we should deal with this. Ensuring the welfare of staff across all settings of care should remain at the forefront of workforce planning and is enshrined in the new NHS People Plan; but it doesn’t tell us how to navigate and dissipate the anger of the public, and whilst this remains unaddressed it is our frontline staff that will bear the brunt, sending them ever closer to burnout, and puts the future of our health and care workforce at risk. And anything that impacts on staff safety, impacts on patient safety. References: Hochschild AR. The Managed Heart: Commercialisation of Human Feeling. Oakland: University of California Press: 2012. World Health Organization. Mental Health and Psychosocial Considerations During the COVID-19 Outbreak. Geneva: WHO; 2020.. Patient Safety Learning have set up a community page on the hub to capture insights from staff on their safety. World Patient Safety Day on Thursday 17 September this year focuses on staff safety. If you have been affected by the issues raised in this blog and want your voice to be heard (whether attributable or anonymously), please share here. Patient Safety Learning will use such insights to highlight the staff safety issues and call for action.

The full impact of COVID-19 has not yet been realised, but what we do know is that we have been navigating with no roadmap or star to guide us. In terms of the three psychological phases of a crisis, we have worked through the initial state of ‘emergency’ where we have had (largely) shared goals and an urgency that made us feel energised, focused and even productive. However, this phase feels like it is in its descendancy and most of us are now in the next phase of ‘regression’ where the future feels uncertain and we have lost that sense of purpose. In my work with colleagues from across health and social care to understand what phase three ‘recovery’ looks like in workforce and wellbeing terms, it is clear that both aspects are starting to get the focus they always should have had but maybe not in the way we would have expected. It has not been cries of ‘more’ staff or money that have been echoing through the corridors, but the cry for ‘different’ and the freedom to make decisions without the shackles of bureaucracy and hierarchy holding the tide of necessary change at bay. In the past, workforce planning has had little shared meaning, and has often been more recruitment planning for a continuation of the same as opposed to thinking about what we need from our teams in terms of availability, skills, expectations, roles and the delivery of care designed around the person receiving it. Wellbeing seemed to be something that only HR considered if there was a staffing issue or high sickness, or even more cynically a poor outcome in survey results, resulting in lots of workshops, fabulous plans, but very little sustainable change. In the initial stages of the pandemic, I worked with a number of acute teams to look at staffing in the short term to face the initial onslaught of COVID-19. This meant looking at variation and where we could adjust care levels safely, planning to deploy a moderated skill mix of staff, and working through the cost of plugging gaps in largely traditional models of care using temporary and volunteer staff, with the hope that the 20% sickness rate wasn’t breached too often leaving us exposed to the hazards of unblocked holes in the workforce. This was acknowledged as an unsustainable and haphazard way of providing care for both staff and patients, which after the ‘emergency’ phase results in burnout, higher sickness, increased turnover, and certainly lacks in the resilience required to continue to manage COVID-19, non-COVID urgent care, elective care and the wellbeing of staff and carers. So, what do we need to do as we plan for recovery, or more precisely ‘post traumatic growth’? Despite an apparent increase in interest in joining the nursing profession since the start of the pandemic, the reported 40,000 gap in nursing numbers is not going to be closed overnight, so it seems that planning for different and capturing and capitalising on the innovation that has flourished in some areas is the only way forward. How do we do this? As an example, let me turn your heads to colleagues in social care who have known for some time that their current state was unsustainable. This has been compounded by COVID-19 and the (inevitable) delayed recognition by government of the essential role of social care in protecting the NHS and some of our most vulnerable people. Therefore, they chose to do for some what is unthinkable – they took their nurses away from direct patient care. In some of the teams I work with there was an expectation that they would have 50% of staff available to be deployed, and would have slower and more limited access to other services to support – including temporary staffing or volunteers. They collaborated swiftly both within and across organisations, changed models of care completely based on some of the data collated by Establishment Genie, and moved to a model of all registered nurses in a supernumerary supervisory role, providing support to staff in their own care home directly and also in other homes via ‘virtual’ collaboration, and using technology to connect, share, teach and learn ‘on the job’. This of course questions the future role of the nurse in these homes but is also an example of how we all may need to re-think roles and responsibilities to meet the challenges of today and the future in order to keep the people in our care – patients, residents and staff – safe. As we begin to reorient, revise our goals and focus on moving beyond rather than on just ‘getting by’, it is important that we look at all settings of care so we can learn from excellence, build on the best, and support a faster response in the future if required. The response to COVID-19 for many has been an example of how a system succeeds in varying conditions; a ‘Safety-II’ approach where humans are the necessary resource for system flexibility and resilience. We need to take the time to understand where things have gone right, to celebrate and acknowledge this, and then co-create a health and social care system that people want to work and be cared for in.

Case study examples The following case studies show how trusts have been using the tool. Roles and responsibilities of staff have been reviewed and new workforce plans have been co-designed with staff at the frontline to deliver new ways of working that put the patient at the centre of care – whatever the setting. The Hillingdon Hospitals - Safety Supervision and Savings.pdfThe Hillingdon Hospitals - Ward Reconfiguration for Safety.pdf GIG Cymru NHS Wales - Residential Nursing homes Case Study.pdfChelsea and Westminister Hospital Case Study - Empowering Staff.pdf GIG Cymru NHS Wales - District Nursing Principles Case Study (1).pdfBerkshire Health Community Nursing Case Study.pdf Organisational benefits Integrated care levels, costs and common language enables clinical and corporate leads to collaborate and meet the requirements of a next-generation health and social care workforce: Precise staffing profiles and options appraisal support CIP development and budgeting. Gap analysis compared to budget and standards for exact hours and WTE requirement for each band. Uplift for leave is specific to each role and expected joiners, avoiding blanket uplifts that may not fit the needs of the unit. Governance and control underpinned by agreed, costed roster templates, with ready reckoners to keep within range. Improved recruitment and retention with evidence of staffing levels and support. Outcomes track quality, with benchmarking to assure. Clinical benefits Professional judgement in workforce planning is supported by this NICE-endorsed tool: Planning care levels and WTE for expansion, efficiency, reconfiguration and new service models. Evaluating alternative shift models to reorganise, invest or save. Modelling skill-mix and impact of new roles. Understanding and validating variation. Challenging peaks and troughs in cover to improve safety, release capacity and release cost savings. Benchmarking and triangulation of patient care levels, with outcomes for correlation. Mapping other staff group input across each setting. Background on 'Establishment Genie' Creative Lighthouse was founded in response to frustration at the focus on financially led decisions in health and social care management that did not consider the safety and care of patients or staff. We set out to build a platform that would allow all management groups in the healthcare sector to collaborate on safe staffing and financial governance. Creative Lighthouse self-funded the development of a unique workforce-planning tool under the brand name ’Establishment Genie’, endorsed by the National Institute of Health and Care Excellence (NICE) in 2017. In April 2017, the Creative Lighthouse team were awarded a grant from Innovate UK to continue to develop the tool to include all settings of care in the knowledge that patient safety and workforce planning is not only the responsibility of acute services, but of all providers and commissioners of care. This is a critical aspect of enabling the improvement of quality and patient outcomes in a cost effective way, whilst providing data driven analytics to support professional judgment. About the author I am a healthcare professional with over 15 years’ experience working in and consulting to public and private health and social care organisations. I have worked with a variety of health and care sector clients in the delivery of complex change, from transformational change and organisational design process to programme leadership and execution. I am passionate about the safe staffing agenda, recognising that in order for any organisation to ensure appropriate care and evidence for professional judgement, there must be consistency in approach and a way of linking staffing levels to quality outcomes that can then be benchmarked within and across organisations. This passion resulted in the birth of ‘Establishment Genie’.