The courage to be kind Reflecting on the role of kindness in the healthcare response to COVID-19

Ben Thurman The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

Enabling Wellbeing Research Kindness in Health & Social Care 2020

ACKNOWLEDGEMENTS We are grateful to all those who have embraced kindness as a value in health and social care in Scotland, giving their time and thought to interpreting emerging themes; to Elizabeth Kelly, whose compassion and understanding guided the project, both as a participant and Carnegie Associate; but most of all to Cicely Cunningham, Grecy Bell, Katy Ritchie and Savita Brito-Mutunayagam, who shared their experiences of the healthcare response to COVID-19 with an openness, honesty and careful reflection that run right through this report.

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B Contents

Foreword 2

Background 3

The approach 6

Phase one: lockdown (April-May) 8

Phase two: lifting lockdown (June-July) 12

Phase three: remobilising (August-September) 16

Discussion 19

Bibliography 23

1 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

Foreword

At the start of this year, there was a gathering ways that infection control had necessitated momentum to conversations about the role changes in practice, and the opportunities of kindness, compassion and love in shaping a this had presented for embracing technology future Scotland. The bold language of the Care and new ways of working. They spoke about Review, the Sturrock Report and indeed the a renewed focus on staff wellbeing and how National Performance Framework all indicated this sometimes felt in tension with more growing acceptance of the evidence, and of operational pressures to remobilise. But the importance of values in public policy. In more importantly, they reflected on their the health and care system, specifically, facing experiences of loss and grief, both personal a period of significant reform and challenge and observed, and on how they were feeling to meet the needs of a changing population during a period of prolonged change, and adopt new technologies, it felt doubly uncertainty and intensity, offering a window important that the prevailing culture should into the experiences of thousands of NHS staff allow room for kindness. across Scotland. Yet, as the Carnegie UK Trust’s own analysis As powerful and insightful as their reflections has shown, the ease with which people now are, we know that they only offer one speak the language of kindness does little perspective, and that they do not provide to diminish the tensions and complexities of all the answers for health and social care embedding it in practice. For public policy and renewal. What they have highlighted though, public services, the implications of kindness are consistently and clearly, is the importance radical and disruptive. of creating space to listen. This is critical in the sense that if we want to provide the best When COVID-19 happened, we entered a possible healthcare, we need to look after the period of rapid change across the public wellbeing of those that are providing it. But it sector in which many of the previously is also clear that the ambitions of health and insurmountable ‘barriers’ to kindness social care renewal can only be realised if they appeared to fall away. This was nowhere build on, rather than stifle, the vast knowledge more the case than in our healthcare system, and skill that is found across the workforce. which was charged with transforming almost overnight to cope with unprecedented The response to COVID-19 has shown demands. what can be achieved when our approach is underpinned by relationships and by In the spring, as we all clapped for carers, we collaboration. If we are really serious about sensed that there was something happening a renewal that focuses on improving the that the Trust decided to capture – not in a wellbeing of staff and patients, finding ways to representative, system-wide way, as there were ensure that we sustain the focus on wellbeing many others better placed to do that – but and on empowering staff is not optional, it’s a rather through a deep, relational approach, necessity. reflecting on the role of kindness in a manner that was underpinned by the value itself. We were very fortunate that a group of medics was willing and able to participate in a listening project that was guided by reflective practice. Over a series of open and Sarah Davidson honest conversations, they told us about the CEO, Carnegie UK Trust

2 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

Background Kindness is something that feels universal: a word that we all understand and, particularly during 2020, place great value on. Yet every so often it has the power to make us stop and think. The Scottish Government has been talking about kindness and compassion as values that are at the heart of its vision for more than two years.1 But when John Sturrock QC’s report on cultural issues in NHS Highland drew the conclusion that “kindness is what is needed”, it felt different: kindness not as a personal quality or an aspiration, but as something that was institutionally lacking and needed to be “restored”.

1 “We are a society which treats all our people with kindness, dignity and compassion…” (Scottish Government, The2018). findings of the Sturrock Review (Sturrock, of scrutiny that can foster a ‘blame culture’. 2019), and the way that these presented, These systems for accountability are meant that they resonated far beyond important, because public services have a NHS Highland. The Scottish Government responsibility to deliver fairness, safety and Response (Scottish Government, 2019) value for money, and therefore must be open acknowledged that there was important to scrutiny and challenge. learning and reflection across NHS Scotland However, the Trust’s research has shown that and for the government itself. In establishing significant risks also exist in a system that does a Ministerially-led Short-Life Working Group not foster and reward the building of strong, (MSLWG) to examine the role of leadership trusting relationships. All organisations are and management in workforce wellbeing, the made up of people, and an organisation’s Cabinet Secretary signalled that this was not performance is therefore hugely affected by an individual but a systemic, cultural issue – how happy, engaged, purposeful and safe its one that required deep consideration of the people feel.2 Leadership really matters, and closing question posed by Sturrock: compassionate leadership is associated with “For those who have been affected, how high performance, effectiveness, wellbeing and will NHS [Highland] move from fear credibility (West et al., 2017). to safety, from anger to compassion, This understanding forms the backbone of from blame to kindness, from shame to Sturrock’s report, in which he foregrounds dignity?” the importance of a leadership culture (Sturrock, 2019) underpinned by a commitment to compassion and kindness; and indeed it is at the heart of The Carnegie UK Trust has been exploring the the government’s own vision for Scotland. Yet, role of kindness and relationships in public by Autumn 2019, the language of kindness policy and public services since 2016 (Unwin, was in short supply in the public narrative 2018). Across four years of research and about the NHS in Scotland. A number of health practice, the Trust’s work has documented boards were placed under special measures, the ways in which kindness can be ‘squeezed’ as government responded to operational from above, by pressures on expenditure and challenges by increasing the pressure on audit a prevailing audit culture; and from below, and scrutiny, encouraged by a parliament and by inflexible approaches towards risk and media dialogue that focused on the personal performance management, and by high levels accountability of individuals in leadership roles.

1 “We are a society which treats all our people with 2 For a more detailed look at the impact of social kindness, dignity and compassion…” (Scottish support, cohesion, and sense of purpose on Government, 2018). wellbeing at work, see (Irvine, White, & Diffley, 3 2018) The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

In this context, the Trust approached Dr conversation and further explore how to create Elizabeth Kelly, to begin an exploratory the conditions for kindness and compassion conversation about the place of kindness within the healthcare workforce. within health and social care in Scotland. In Across six months of exploratory conversations particular, it sought to explore the relationship there was an urgent feeling that the health between individuals and the system that they and social care system – with an ageing work in, which creates the context for the ways population and rising demand, with the they behave; and to interrogate what might regular deployment of special measures, with need to be done to create the conditions for increasing levels of staff sickness and absence5 healthier relationships – conditions that bring – was staring at a crisis. In March 2020, a the best out of Scotland’s health and social very different type of crisis emerged, one that care workforce, and the people they care for. forced the cancellation of the cohort’s planned Throughout Autumn and Winter 2019, talking engagements, but also opened up an array of to leaders in healthcare using a snowball new thinking and possibilities. approach, it became clear that there was a The immediate response to the COVID desire among segments of the clinical and emergency saw rapid change: many things leadership community – in Scotland and that previously felt impossible suddenly indeed across the UK – to talk about kindness. became a reality, as people and organisations Sometimes this was framed in terms of united with a sense of common purpose. While psychological safety (Jones & Seager, 2019), the focus remained, rightly, on managing at other times compassionate care and the public health crisis, at the same time it relationship- or person-centred care; elsewhere felt important to capture the experiences of it was a broader conversation about values- those working within this time of change. To based leadership. But throughout was a understand what was being learnt about new recognition of the influence of a triangular axis ways of working, to reflect on what was being of politics, media and audit culture, which puts valued in decision-making, and consider what pressure on staff working at all levels of ‘the this might reveal about priorities for recovery system’; and of the importance and urgency and renewal. of focusing on staff wellbeing. The Trust therefore developed a model There was particular energy among a smaller that provided a safe space for the cohort of cohort of emerging leaders: four members of leaders to reflect on changes in real time. By Project Lift and the Scottish Clinical Leadership working with a cohort that offered a range Fellowship were interested in exploring this of backgrounds and perspectives, it aimed conversation further as part of their leadership to ‘walk alongside’ the NHS during the crisis, 3 programmes. Coming into 2020, this cohort and capture learning and insights on the created platforms and opportunities at a series project’s key question: What can we learn 4 of engagements at national conferences, the from the COVID-19 crisis about relationships purpose of which was to widen the and collaboration in Scottish healthcare environments?

3 For more information about Project Lift and the Scottish Clinical Leadership Fellowship scheme, 5 For the financial year 2019-20 the sickness and see https://projectlift.scot/ and https://www. absence rate across NHS Scotland was 5.31%, set scotlanddeanery.nhs.scot/your-development/ against a target of 4% or less (Health Performance leadership-and-management-development/ & Delivery Directorate, 2019); NHS data in England scottish-clinical-leadership-fellowship-scheme/. shows that anxiety, stress, depression and other psychiatric illnesses account for nearly a quarter of 4 These included: the Scottish Access Collaborative, the staff absences (Copeland, 2019). Evolve Scotland, Faculty of Medical Leadership & Management, Scottish Medical Education Conference, NHS Scotland Conference. 4 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

The evidence consistently shows the “…it’s important to be kind to importance of relationships and the quality staff, otherwise they won’t have of interactions for health outcomes. While the reserves to bring that into insights from these conversations are from the their work and interactions. [But] perspective of clinicians, they relate to both if you have staff that are being patient experience and population health, and looked after, this will permeate indeed, throughout the project, conversations into how they are with patients.” consistently returned to this theme:

5 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

The approach

In April 2020, the Trust invited the cohort In the end, the project completed two rounds of four emerging leaders plus Carnegie of one-to-one conversations in May and in Associate, Dr Elizabeth Kelly to take part in a June / July, at which point participants saw series of reflective conversations. With those value in coming together for a final group involved in elective leadership programmes reflection, which was held in early September. having returned to clinical practice, the five After each round of conversations, the participants in the project were able to reflect Project Officer and Carnegie Associate spent on the COVID response from roles within time analysing the key themes, which were Scottish Government, local health board summarised and shared with participants management, hospital medicine, emergency for input.7 As such, the boundaries between department and general practice. This ‘researcher’ and ‘participant’ were somewhat meant that they offered a range of different blurred: this was not a formal research project, perspectives; but their insights remain a but rather a collaborative reflective practice snapshot, rather than an attempt to portray a (hence the use of the term ‘conversations’ as representative picture. opposed to ‘interviews’). In particular, it is worth noting that all five The aim of the project was to create a space participants were medical doctors in the NHS; for open, honest reflection that might not be and while they spoke of practical change in possible in normal workplace settings. This was health and social care, their reflections are one enabled, in part, because of the relationships particular perspective, albeit one that chimes that had been developed before the project with the Trust’s understanding about kindness began. The approach to these conversations during COVID across a much wider range of was also influenced by elements of Values settings.6 Based Reflective Practice® (NHS Education for From the outset the project timeline was fluid, Scotland, 2020), with participants given space in order to accommodate the uncertainty of to reflect in both a personal and professional the duration and impact of COVID, and the capacity on themes that align with the way that the changing situation might affect five ‘NAVVY’ questions.8 In structuring the those working in healthcare environments. conversations in this way, it was hoped that The aim was for the Carnegie UK Trust Project they would be beneficial to participants in and Officer to conduct bi-monthly one-to-one of themselves, through offering a safe, non- conversations, that were loosely structured judgemental space for listening at a time of around working through the following heightened pressure and anxiety (West & Coia, questions: 2019) (this theme is discussed further in the thematic analysis). • What are you noticing and learning about relationships / kindness? • What reflections do these prompt about how things were before COVID?

• What changes in practice and behaviours 7 Emerging findings were also shared in real time do you want to keep post-COVID? with a small group of people at the Scottish Government. 8 N: whose needs are met; whose needs are overlooked? 6 This includes a case study on kindness in North A: what abilities/capabilities are at work? Ayrshire (Thurman, 2020), a UK communities V: what voices are present/absent, included/ listening project (Coutts, et al., 2020), as well as excluded? unpublished conversations with members of the V: valued/undervalued/overvalued? Trust’s Kindness Leadership Network. what is being 6 Y: what does the situation reveal about you? The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

Because of the openness and honesty with The remainder of this report presents a which participants shared their experiences thematic analysis of what was heard across – both personal and organisational – and these reflective conversations. It is structured because of the relatively small numbers of chronologically and, in doing so, it tells a story people in each Project Lift and Scottish Clinical of people’s experiences of change across the Leadership Fellowship cohort, confidentiality NHS through three distinct phases: lockdown has been an important consideration. This is (April-May), lifting lockdown (June-July), and particularly the case in the presentation of remobilising (August-September). Each phase examples, where the report anonymises the is broken down into key themes, with the voice individual and, at times, the context, which is of participants woven between. The report to ensure insofar as possible that the identity finishes with a discussion that summarises of both the participant and those they work what has been learnt about kindness and with is not discoverable by others. relationships in the first six months of COVID, and considers what this might mean for the future.

7 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

Phase one: lockdown (April-May)

The first round of reflective conversations was held with each of the five participants between Friday 1st and Monday 25th May. Several participants had recently returned to clinical settings that had “changed beyond recognition”; others had spent several weeks reacting and adapting to a rapidly changing environment. This round of conversations, then, focused primarily on what people had noticed across April and May: they blend a sense of energy and fulfilment in what had been achieved at pace in the immediate COVID response, with a powerful recognition of the emotional impact of change and loss, as well as a mix of optimism and anxiety about the future.

Staff wellbeing. Participants spoke But overall, the feeling was one of cautious passionately about the renewed focus on staff optimism that the importance that had wellbeing, not as an added extra but as a core been placed on staff wellbeing would sustain part of ‘what we do’. There was a sense that beyond COVID-19 lots of the things that had been talked about, “Perhaps that could be one mitigation but seen little action, had suddenly become of this whole environment – the PPE, possible; and there had been a realisation the separation, the feeling of being that you have to be kind to staff, if you want unkind – that this idea will carry kindness to be present in their interactions and through: if you have staff that are relationships. being looked after, this will permeate “…things that had been talked into how they are with patients.” about for a long time were suddenly Personal impact. The focus on wellbeing, and possible. Overnight people provided (for some) the knowledge that they worked free transport for health workers, set up in an environment where it was easy to say staff lounges in hospitals… The way if you were having a tough day, was of great that barriers just parted for wellbeing importance because of the personal and and support was amazing to watch.” emotional impact of COVID. Conversations There was some scepticism about wellbeing were underpinned by a sense of loss: direct initiatives that prioritised tools and (online) loss of patients, loss of human connection in resources for individuals. When thinking clinical environments, loss of Project Lift / SCLF about their own wellbeing, the things that opportunities and a broader recognition of the participants valued most were protected loss experienced by people and families across spaces for reflection (like those provided within the country. leadership programmes and by this project); “The last two months have been and the sense that they were listened to by couched in change and uncertainty. As senior management and decision makers. a doctor, the loss of practice as I know “One of the positive things was being it has been really tough.” asked by clinical management what Although some were energised by working we think is working well. It made us feel in an environment where it felt possible valued and listened to, and that’s the to get things done, the “intensity of it all” best thing for group wellbeing: knowing was challenging (a theme that developed that senior management value our throughout the summer). In addition, experience and insight.” 8 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

participants reflected on the diversity of relate to each other. There is also a experience within the NHS. They spoke of the sense of pace: both the urgency of the levels of redeployment and underemployment situation and desire to make it better, across the health service: the necessity which has driven a positive individual of infection control and temporary pause and group response.” of certain operations left some people feeling frustrated and impotent – a striking Participants perceived that the crisis had counternarrative to media discourse at the seeded a response that prioritised health time. outcomes and was less concerned about governance and procedure – and that “a lot of “[It’s not like] the narrative in the things that would have been barriers, weren’t media. I hate the war metaphor, and a factor because of the emergency nature.” the NHS heroes metaphor. There are all But there was also an undercurrent of worry those images you see in the media of about what would happen when this common ICUs – but then there’s a whole swath purpose subsided, with some already noticing of departments that are mothballed. the return of certain behaviours and people It felt like there was so much energy trying to “own their space”. around where we might be deployed at the beginning, but it’s all come to Re-evaluating performance. Several nothing.” conversations highlighted that COVID-19 had “given permission” to stop doing things Common purpose. Across the piece, people that are non-essential. They recognised spoke about the speed of change, reflecting that previously certain procedures and on how much could be achieved when urgency appointments were “often done for the benefit and a common purpose demanded working of the service rather than the person”; and together. noted the impact of dialling down pressure on targets, which, in some places, had given staff “This was possible because of a shared greater understanding and flexibility to provide understanding and a shared fear. There a person-centred response, and generated a was no space for personal ambitions less punitive environment around performance and agendas, because there was management. something bigger and more frightening that demanded our attention.” “Overall, the four hour target is a good thing […] We know that we have to be In all settings, communication had become as vigilant as we can with targets, but more regular (despite the challenges of being punitive and aggressive towards physical distancing), an investment of time staff is not helpful. It we take each one that participants felt had strengthened on case-by-case, and always ensure the relationships. Territorialism and hierarchies best thing for patient, we shouldn’t be fell away, unlocking partnership and criticised.” collaboration “that wouldn’t have happened before”, particularly in health and social care At the same time as recognising the integration and the recognition of “community importance of lifting some of the weight solutions”. of ‘audit culture’, participants also noticed growing pressure to get services operating “The main change is the common goal: again. In ‘returning to normal’, people everyone feels that the only way to get wondered about the risks of reinstating the through is working together, which has previous performance management structure, taken away a lot of the barriers and which could squeeze out the space for made a huge difference in the way we wellbeing of both workforce and patients.

9 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

“How do we keep the system going in however, noted that the starting point must a new way without going back to the be the wellbeing of patients and staff, using old way? Who gives permission that technology to complement this, rather than as this time next year we start to look a tool to drive performance and efficiency. at a different type of performance Alongside the more positive changes, management? We know what can there was also a great deal of uncertainty. happen when we have consensus on Participants voiced anxiety about those who priorities; but something has to be were not seeking medical attention for serious taken out of the system to create the health issues, and the impact this may have space for kindness and relationships.” in the coming months. Similarly, they worried Changing practice. Alongside shifting about the long-term impact of physical attitudes and approaches at a systems level, barriers to human connection. While everyone conversations also brought up more specific spoke of doing what they could to mitigate the changes in practice, noticing how infection dehumanising nature of PPE and restrictions control measures had necessitated rapid on visitors, there was concern both that this changes in the way healthcare is delivered, was reducing their ability to understand what some of which could improve patient is important to patients, and that operating outcomes. First, the sudden availability of in what feels like an unkind environment for a hospital beds and a transformed layout and sustained period of time would take a toll on approach in emergency departments provided workforce. an opportunity to look at hospital capacity: “It doesn’t feel like a very kind place specifically, to ensure that ‘corridor care’, right now […] We want to be someone which impacts both patients and staff, does who is accompanying a person, who not return to the healthcare system. is with them in their suffering, but it “Hopefully the emphasis on infection is really hard to portray empathetic control will prevent there ever being listening without people seeing your such a problem with corridor care in face. “ ED […] This can’t happen anymore Command & control. Two months into the due to infection control. There is pandemic, there was a broad consensus that an opportunity to never go back a centralised approach had been necessary to having patients stacked up in a and had resulted in broadly effective corridor, where we felt we weren’t decision-making in the immediate response. providing very good care – and where Participants did, however, reflect on the the evidence shows outcomes are medium- and long-term approach to decision- much worse.” making. They perceived potential tensions There was also recognition that the sudden between central government and NHS boards; widespread use of remote consultations, and a risk that sustaining this approach would enabling outpatient and follow-up undermine the ability to respond to local and appointments to be managed at a distance, regional circumstances, and thereby cut across had the potential to deliver a more person- person-centred care. centred service. This perception linked to the theme of COVID putting non-essential functions on pause, presenting opportunities for renewal to refocus on responding flexibly to the needs of individuals, which vary across situation and geography. It was,

10 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

“We’ve been able to deliver huge “There’s huge amounts of opportunity amounts of change – as individuals, to deliver relational services. We have society, professionals and at a political taken away performance management level. But if we don’t change the and micro management; we’ve model of decision-making soon, we fostered creativity and working will have an increasingly centralised together; there’s been a real cohesion framework [that is] very operational between previous turfdoms. We need and performance driven.” to celebrate the really good stuff that’s happened and build a better society.” This final point of reflection epitomised the conflicting emotions in the conversations that were held in May. Because of the speed of change there was a sense of opportunity to build on what had been achieved in the immediate response to COVID-19, by creating space in the system to allow people to focus on relationships. But participants also recognised the risks of “going back to the old way”, and the critical importance of leadership to strike the right balance between performance metrics and governance, and valuing staff and patients.

11 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

Phase two: lifting lockdown (June-July) Across the second round of conversations, held between Friday 5th June and Thursday 2nd July, participants reflected on a period of change and transition, from ‘hard lockdown’ towards a resumption of health services. At times, the energy and optimism that was present in May remained; but there was also a growing fatigue as workload intensity, decision-making responsibility and prolonged uncertainty began to take a toll. People were also noticing that elements that were strong in the immediate response – the common purpose, the flexibility, the focus on listening and on wellbeing – were fading away. This perception, alongside increasing pressure to return to normality, triggered a sense of urgency to grasp opportunities for change.

Staff wellbeing. Three months into the “Big organisations perhaps struggle crisis, there was a subtle change in the way to think about people at a human that people spoke about workforce wellbeing. level [and] there is a tendency to look Participants continued to recognise the energy for a centralised solution, which just that had been put into particular initiatives, doesn’t work. We don’t operate at a like rest and relaxation hubs and psychological health board level. You only really know support. But they also began to perceive a what works for your little bit of it, and tension between investing time and resource in the end nothing really substitutes in staff wellbeing, which could otherwise be for individual, human action based on directed at patients. understanding of a person – you can’t “I’m nervous about this. There is a mandate or scale that.” level of weariness among people who Personal impact. By the summer, this have been managing the response, conversation about wellbeing felt especially and a fear that, despite all the important because of the mounting personal emphasis on staff wellbeing over the and emotional toll of COVID-19 on the past three months, we could go back healthcare workforce. Reflecting on both to business as usual.” personal experience and perceptions of the In addition, they noted that the most healthcare community in general, people effective approaches to wellbeing happen spoke of “weariness, fatigue and anxiety about at a local level, and are based on human what the future may hold.” It was suggested relationships. While remaining positive about that this might be particularly the case for the national narrative and focus on wellbeing, colleagues in ICUs, sustaining high workloads some questioned the way that it was being and experiencing the human impact of COVID operationalised. Rather than looking for on a daily basis. But it also felt important to formal, one-size-fits-all solutions, there is a recognise that the pandemic was affecting need to create the space and flexibility for everyone, regardless of decision-making kindness to happen between individuals and responsibilities or workload intensity. teams, informally, intuitively and often in the “It’s been quite tough emotionally, margins (a flexibility that demands shifting even though there hasn’t been control away from the centre). the influx of patients we expected. Personally [and also] at work: the constant awareness of your own space, walking down the corridor, being afraid 12 of being too close to others…” The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

In this context, several participants felt a Alongside practical implications, there was a need to pause and reflect with colleagues sense of change fatigue as participants began – not about the practicalities of work, but to talk about how hard it was to keep up with about “how we all are”. They observed the a situation that “changes every week”, and challenge of creating space to do this, and to voice their anxiety about all the unknowns the importance of leadership in ensuring that associated with COVID-19. there is time to prioritise the needs of staff “Activity is still way down on normal, and teams, especially when workload pressure and we’re wondering what is makes this difficult (a theme that should happening, and where the patients inform organisations’ and teams’ approaches are […] There is uncertainty about to staff wellbeing). the people we’re not seeing, what we “It’s also important to have these might be missing, what is the impact of catch ups on a pastoral level: putting what we’re not doing. That uncertainty everything else to one side, how are is hard to manage.” you feeling about all this? It feels like Listening & being heard. As people reflected this is missing. There are meetings, but on the impact of change and uncertainty, they are specifically about the rotas. they noticed that the way they felt about We know there are colleagues who are change was affected by the extent of their worried about a whole range of things, involvement in decisions. At a local level, and this can impact how they are at conversations highlighted the importance of work.” communication and transparency, so that Change & uncertainty. While acknowledging staff understand why changes are happening the necessity and inevitability of evolving and how their feedback has been considered. measures to control the virus, the resulting Among the wider clinical community, there “constant flux and change” emerged as was a sense that they were listened to during a key theme. People spoke openly about the acute phase, and felt empowered as a the implications of test and trace: not as a result; but a worry that things were “slipping critique of infection control measures, but back into old ways” as priorities began to as a recognition of their impact on staff. In change. some settings this meant putting measures “It’s important to have everyone in place that introduced further barriers to involved in how they think things human connection; in others, the challenge could work. People get grumpy when of adapting systems to manage increasing you ask them to change if they don’t numbers of patients with reduced spatial understand why you’re asking them to capacity. do that.” “In practice, we have to see patients Common purpose. Although the unity within 15 minutes, and at least 2 and collaboration that everyone noticed metres apart […] This means putting in May remained, there was a sense that more barriers in place to ensure it it was beginning to dissipate as plans for stays in control, making interactions remobilisation opened up new priorities. One much quicker. It feels very sterile at the indication was that the regular communication moment because all the focus is on across different departments – on which the controlling infection – and none of the initial response was built – was being rolled healing things. We don’t really know back, as people’s focus shifted. what the repercussions of this will be. But two months into it and there’s a sense that people are starting to flag.” 13 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

“The shared sense of purpose is still “…turning off targets has allowed there, but with less intensity. The different ways of working and [staff] common goal is changing, because don’t want to go back to a target it’s opening up different priorities. And culture […] to unsafe levels of the pressure from above to return to crowding, neglect of staff wellbeing, normality is intensifying.” systemic failure to meet 95% targets.” 9 These observations were pointed: participants emphasised that it was this common purpose, Opportunity to grasp change. Running cohesion and strength of relationships that alongside these pressures, was a sense of had allowed health and social care in Scotland opportunity to hold onto the things that to achieve so much at such space. They spoke COVID-19 had made possible: to build on of a desire to “keep it alive” and hold onto the technology and community solutions; to (not) sense of a common goal as conversations focus on things that (don’t) offer value to turned towards remobilisation and recovery. patients; to revolutionise A&E so that it is a “safety net for the patient, not for the system”. Pressure & urgency. As people noticed That optimism was present, in part, because subtle shifts in language and approach, of a feeling that resource scarcity will demand the conversations felt more urgent. People moving “from high volume to high value” recognised the critical need to resume healthcare – and that returning to a system services that had been put on hold, and that was unsustainable before COVID-19 is felt the pressure of “ambulances stacked not a viable option. up at the door”. Yet, at the same time they worried that the emphasis on remobilisation But people also recognised that this is might indicate a desire to return to normal, “complete institutional change” which would and diminish the possibilities for building a require communication with everyone different future. involved and, above all, time and space to move beyond health and social care silos, and “What is increasing is the pressure sustain and develop a common purpose. To to restart services without enough grasp these changes, there is “a need to slow consideration. I really don’t know down a bit”. where that impetus to get back to some degree of normality is coming “There is potential to revolutionise the from – does it mean just going back to way we do things. […] We need to use the way we were before?” what’s happened now as momentum to implement these kind of changes There was a feeling – among participants – but we need board support for that. themselves and their perception of the wider This is complete institutional change, clinical community – that so much had been and so it needs communication with achieved because dialling down targets had everyone involved, so it’s not about enabled different ways of working. And there people jumping in with their own was a level of fear in the way that they spoke agenda.” of the system as “a juggernaut revving up”, which might instigate a return to the way things were before.

9 LDP Standard: 95% of patients to wait no longer than four hours from arrival to admission, discharge or transfer for A&E treatment (Health Performance 14 & Delivery Directorate, 2019). The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

Collaborative leadership. Woven throughout “After all the plaudits that workers in this second phase of conversations was a health and social care have received, sense of people and a system being pulled that trust and respect must continue. in different directions: between human How can we capture that expertise relationships and infection control; between and deliver something that’s new valuing the workforce and struggling to carve and different? That will take brave out time for wellbeing; between remobilising leadership from politicians and and holding the space for a conversation government.” about what a different health service would look like. Another tension was between the centre and the local. Here participants spoke about the importance of listening, engaging and embracing a truly collaborative approach, so that leaders at all levels have a voice and feel part of what ‘the new’ looks like.

15 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

Phase three: remobilising (August-September) On Tuesday 1st September, the cohort came together for an online session to share what they had noticed, and reflect collectively on what that might mean for recovery and renewal. Structuring the conversation in this way elicited insights reflecting back on the experience of the last two months, and perceptions looking forward to the future, identifying positive changes that need to be sustained beyond the crisis. Phase three of the project came at a time when case numbers were relatively low, and there was still an appetite for discussions about ‘getting back to normal’ or ‘building back better’ across society. And yet, despite this, there was a palpable sense of tension, and of people holding conflicting pressures and emotions – the energy and optimism about possibilities for renewal, with tiredness and anxiety about preparing for winter – often at the same time.

Reflecting back “My soul feels anxious, and I am not normally like this. I am optimistic. But Personal impact. Even in a group setting, the now less so.” personal and emotional impact was palpable. At times the conversation was animated and Connection & loss. Alongside uncertainty energised about the possibility of change; in about the future, the group reflected on the other places there was a sense of exhaustion present reality of clinical practice. Perhaps and anxiety, particularly about the prospect of reinforced by the validation of shared winter which people already recognised as “a experience, the sense of loss which had been huge challenge”. These conflicting emotions present throughout the pandemic felt stronger were often expressed by the same people at than before. In some cases, somewhat different times, something that felt particularly contrary to the idea that technology would pronounced for those who were involved in bring ease and efficiency, people spoke about planning and preparation. how tiring they found back-to-back telephone calls. But most of all they spoke about missing “There’s an urgency to be ready for “the things that happen in the appointment” winter. For me and the teams trying that can’t be replicated through technology. to get people into a place where they can be prepared, it is taking a lot of “It feels very transactional rather than emotional energy in terms of being holistic. You listen to a problem on able to support officers, and drive the the telephone and that’s what you things that we are being asked whilst manage – you don’t look at it in the getting ready for a second peak and whole.” winter.” There was no critique of the approach being Here, it felt like the cumulative effect of being taken to control infection – and indeed asked to respond, remobilise, adapt and elsewhere people spoke about the possibilities prepare – all while trying to maintain the level that technology presented. However, it did of optimism required to drive change – was feel like people valued the space simply becoming unsustainable and might be having to recognise that working in this way, a real impact on individual wellbeing. feeling disconnected and not being able to provide the care that you would otherwise is emotionally hard. 16 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

Values & culture. These discussions about Public expectations. As well as the top-down how people were feeling, led to a conversation pressure to remobilise, people also felt the about wellbeing at work that questioned weight of public perception that the NHS is whether the values that were being expressed open. There was recognition that there had publicly were truly reflected in their experience. been huge adherence and compliance with As in previous phases of the project, there was the restrictions and guidance across society, a consensus that staff wellbeing was “really but now there was a weariness about living prevalent” in conversations across the service; with COVID, and a growing expectation and that people had been “humbled that the around access to healthcare, which the service values of the NHS were being celebrated” at a was not always in a position to provide. national level. Yet, people wondered whether “In general practice, the doors are this translated into reality, and articulated shut, and people are starting to get the challenges of maintaining the space for frustrated and angry.” wellbeing and driving culture change. Beyond the immediate concern, participants “From being involved in various things worried that there simply would not be the to do with wellbeing and culture, one resources to create the systems that the public of the challenges is to identify what would like to see, and predicted that it could you can actually do. People are well be “pretty dire in terms of waiting times and intentioned and try to do the right elective surgeries”. In this context, they spoke things, but it always somehow ends up of the need for an “honest conversation” with getting sucked into discussions about the public, one which would aim to embed process and targets.” the ethos of realistic medicine; but noted Renewing & remobilising. At the heart that this type of conversation would require a of all of these discussions was a feeling of fundamentally different relationship between tension between the hopes of renewal and the politics, policy making and the media. pressures of remobilisation. Participants felt the sense of common purpose dissipating, as people started “going back to different parts Looking forward of the system”, their focus returning to more narrow departmental and organisational “Changes are not necessarily bad, but priorities. While some of this was inevitable, or we need to acknowledge what has at least anticipated, people voiced concerns shifted and what that means.” about the focus on “getting back to normal” Bringing everyone together in September felt without knowing what it was that they were like a different type of conversation: partly aiming for. There was a feeling that this would because of the group dynamic, but perhaps risk reconstructing how things were – “targets more because of the shifting pressures across by another name” – rather than something the health service, which caused people to based on the voice and relationships that had wonder whether the possibilities for change been at the heart of so much of what was that felt so powerful at the start of the strong in the pandemic response. pandemic would be realised. This felt urgent, “There are concerns from everyone. and as the conversation turned towards the There was a pause and we hoped future, participants identified a set of principles it would be an opportunity to re- that might help sustain the positives. evaluate. But now there’s this focus on • Communication. In reflecting on what bureaucracy and returning to normal, was valued and prioritised at the beginning and I’m not sure how we create the of the pandemic, people spoke about common purpose and align our activity the strength of communication across with it. I’m not sure that cultural shift departments as the cornerstone of an within the NHS will ever happen…” 17 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

effective response. In places, they had • Spaces for listening. Yet, alongside perceived this beginning to slip back, as what might be considered more strategic services felt the pressure to remobilise considerations, perhaps the most “based on the experience of what was, powerful message to come through these not what might be”. But there was a clear conversations was the importance of sense that openness and communication – providing spaces for listening.10 The series both horizontal and vertical – would be at of conversations captured some of the the heart of sustaining a holistic approach physical and emotional burden that people to health and wellbeing beyond the COVID are carrying; and those involved spoke response. about how they valued the opportunity to pause and reflect as part of the project. • Innovation. Participants recognised that In this regard, the recent focus on staff the pandemic had triggered a “discovery wellbeing is therefore welcome; the that there are some things we could have experience of this group suggests that it done differently”, implementing practical could be improved by ensuring that people change at speed, particularly through have protected space to be listened to, and embracing technology. These innovations heard. held the potential for delivering a much more person-centred approach to “I’m noticing the importance of healthcare delivery; but there were also stopping and taking time to reflect, “tensions between old and new”, and because the feelings of loss and uncertainty about who decides what to change have been significant, and keep, and where the permission comes the way we’ve been practising has from. altered dramatically […] I see people exhausted. I think there’s something • Collective leadership. There was a sense about how we support each other.” that the early days of the COVID response might offer a framework for navigating this change and innovation. People recognised an enabling environment – borne out of necessity – that had allowed teams “to get on with it” and unleashed the potential of a more collective leadership. This was described in terms of “letting the leadership and knowledge come from where it needs to”, rather than a top-down, command and control approach.

10 This theme is discussed elsewhere (West & Coia, 2019), but the term itself is borrowed from Brigid Russell and Charlie Jones, who developed the concept and practice of #SpacesForListening over 18 the course of 2020 (Jones & Russell, 2020). The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

Discussion This is not the only report to document the experiences of those working in the health service and the changes that have been brought about by COVID-19, nor is it the most representative. It does, however, offer a perspective – one that is valuable because of the project’s more intimate, relational approach, which brought a depth in reflection that can complement and enrich more quantitative interpretations. The reflective conversations enabled a level of openness and honesty that went beyond what people are often comfortable and willing to report in staff or membership body surveys. This human and emotional understanding of the impact of COVID-19, as well as the professional, has to form part of the conversations about how to build cultures that bring out the best for both patients and staff.

In addition, the group’s collective insights infection control, the general public fatigue reflect and reinforce both the Trust’s longer- about ongoing and fluctuating restrictions; term evidence base on kindness in public and to recognise the impact that this might policy (Unwin, 2018), and the conversations be having on staff. This is a workforce that has we have had with public sector leaders during been under constant stress, having gone from the COVID-19 crisis (Coutts et al., 2020; crisis, to remobilisation, and back into a second Thurman, 2020). In the coming months, it will wave, with no respite; and now managing a be critical to find ways to listen to the diversity COVID winter without the same visible level of of experience across health and social care public goodwill valuing the NHS that was so in Scotland, and to build this knowledge and present in the spring. understanding into decisions that are made In this context, it might feel like a strange time about renewal. But the five voices that have to reflect on the learning from the healthcare been heard in this report have already laid response to COVID-19, and what this might down a challenge. Their reflections act as a mean for the future. But what has been heard reminder of how difficult it can be to work in in these conversations is that creating the certain parts of the NHS, and that the solutions space for a conversation about kindness is are not about wellbeing programmes or never more important than when systems are overtly valuing healthcare workers – welcome under most pressure, and workforce wellbeing though these are. The solutions require radical, is most affected. systemic change. Alongside this, the themes emerging from this When the final group conversation was held project have re-emphasised the relevance of in September, the discussion about change the Sturrock Review. These are not pandemic, and renewal felt a live one. Although people but systemic issues that were around long voiced real concerns about the winter, and before COVID-19, and there is work to be done anticipated that remobilisation might be to create cultures and leadership with kindness stymied by rising caseloads, a second wave at the centre. The current context provides an was very much on the horizon. At the time opportunity to take stock what is being valued of publication, this is now the reality. And so in the health service in Scotland. it feels important to acknowledge the rising number of cases and deaths, the growing waiting lists, the reduced capacity due to

19 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

A culture of kindness Although they reflected shifting dynamics, 2. Sustaining a common purpose. pressures and emotions, the three phases of Especially in the immediate, crisis response, conversations present a clear focus on what is there was a clear message about how much important, and an indication of what should could be achieved at pace when people be valued and prioritised in health and social were united by a common purpose. The care renewal, in order to build a system that clear focus on COVID-19 demanded and looks after the wellbeing of patients and staff. enabled a more relational approach: people noticed that improved communication had A meaningful conversation about 1. unlocked effective partnership working; wellbeing that innovation and changes in practice That each section of this report opened were directed at achieving the best possible with participants’ reflections on the outcomes for patients; and, more widely, personal impact of the COVID-19 response that kindness had become a feature of is intentional, highlighting the strength interactions among staff and leadership. of the message about the need to create But they also recognised that this was only time and space to attend to how people possible because the NHS stopped doing are feeling. Too often the individual can so much. As participants felt competing be overlooked in conversations about priorities and behaviours beginning to the system; add to this the context of return, there was a desire to find ways COVID-19 and the sheer exhaustion that to retain the common purpose, and for is being felt across the health service, renewal to build on the partnerships and and staff wellbeing becomes ever more relationships that were at the heart of an important. The commitments in the effective pandemic response. Programme for Government (Scottish Government, 2020) around mental health “There is a common purpose […] and and wellbeing support are welcome, everyone wants to feed in and have and the engagement with the National shared ownership of it. It’s silly really, Wellbeing Hub11 over the past six months because that purpose was always only serves to underline this point. However, there, but somehow it got lost.” the conversations also spoke about creating spaces at a local level that are 3. Shifting the emphasis on targets more relational and more human, and how Alongside the common purpose, people competing pressures and priorities make it reflected on what was possible when the hard to carve out time to prioritise this. pressure of the pre-existing performance management system was relaxed. “We’re trying to create those reflective Throughout the conversations there was spaces within teams [and] we need to regular acknowledgement of the good that make a conscious effort to create and targets have done, and of their ongoing value those spaces. But that permission role in ensuring that the NHS is able to to recharge and recap needs to be deliver certain evidence-based standards. given, especially from SG [Scottish Yet, there was also a recognition of the Government].” negative impact of an overbearing target culture. People spoke about the language of ‘breaches’ and a sometimes-punitive response to missing targets, which can encourage the sorts of behaviours that were reported in NHS Highland. They also noted 11 See https://www.promis.scot/. 20 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

how too great an emphasis on outputs can Scotland, directors and chief officers in the inadvertently lead to ‘gaming’, with staff Scottish Government are under pressure to incentivised to focus on the needs of a deliver, which means that the Chairs and service rather than the needs of the patient, Chief Executives of health boards are too. in a way that cuts across both collaboration Ultimately the media scrutiny of Ministers just and person-centred care. Recognising that shifts pressure to other places in the system, there are no easy answers, the hope was inevitably from those making decisions to that the experience of COVID-19 would those working in patient-facing roles. open up a much wider conversation about The Trust’s interest in securing the role of how best to fit targets to a system in a way kindness in healthcare is in delivering better that delivers the best for both patients and outcomes and improving societal wellbeing. staff. This conversation about the pressures within the healthcare system matters for two reasons. First, because the purpose of performance A new conversation management should be to improve health Given the nature of this reflective listening outcomes. If at times this leads to processes project, it is not appropriate to end with a set that are “in the interest of the system, not the of recommendations. What feels important, patient”, or if it squeezes the space for human is to set the tone for a different type of relationships which are at the heart of better conversation, one that creates space to listen health outcomes, then there is a need to to the full range of voices in health and social challenge the assumptions on which decisions care in Scotland. Having observed the way that are being made, and the targets and indicators authority – and pressure – filters down through to which health boards are held accountable. the system, the permission for this may need But it also matters because it is both unkind to start at the top. and unsustainable to demand that these pressures and tensions are held by those Before the pandemic, the Carnegie UK Trust charged with caring for patients on a day-to- had begun to explore the role of a media- day basis. The levels of sickness and absence politics-government axis in driving the across NHS Scotland were unsustainable culture and behaviours within the system. before COVID-19 (Health Performance & The evidence shows that there is widespread Delivery Directorate, 2019), and this will only public support for the NHS (Reid, Montagu, & become more acute as the workforce begins Scholes, 2020), and that trust in practitioners to feel the long-term impact of the pandemic is high; but this is not the narrative that is response. There is an urgent need to ease carried forward in the way that leaders are some of the pressure in the system in order publicly held to account. The current levels of to safeguard the wellbeing of staff, which is scrutiny over resources and waiting times have intimately connected with the wellbeing of the contributed to a highly pressurised political patients they care for. environment, which influences both behaviour and decision-making. COVID-19 has shone a light on all of this, and also shown that it is possible to work in This observation echoes what has been found a different way. In doing so, it has opened across the public sector, where leaders struggle up an opportunity to rethink and reform the to create the space for transformational health service in a way that builds on the change while at the same time remaining strength of what has been seen in 2020. But accountable for targets and performance translating this into lasting change will require indicators that are increasingly hard to deliver open and honest dialogue with people right (Wallace, 2019). In the health service in across the sector; and this must happen now.

21 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

In publishing this report, the hope is that it “We still have the kindness in the way is the approach, as much as its content, that we communicate with each other; but influences what happens next. Because it it can be eroded when we’re under is only by listening deep and wide, and by pressure, and we just try to switch to embracing the vast collective knowledge command and control. It’s a constant within the health service, that it will be possible balance between emotions, the needs to truly recover and renew. of the service, your resilience, your kindness.”

22 The courage to be kind: Reflecting on the role of kindness in the healthcare response to COVID-19

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This report was written by Ben Thurman

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