In the increasingly demanding and challenging health care environment, the health and well-being of staff is crucial. Supporting staff well-being does not always have to cost huge amounts of money or take up too much time. Sometimes all it takes to get the ball rolling is someone who listens.
One of the defining periods in my professional life was the period I was assigned as the designated complaints officer of one of the larger psychiatric hospitals in South Africa some years back. I was struck by the amount of complaints (from both staff and patients) that originated from not feeling heard or listened to.
I got increasingly interested in understanding the “whys” of this phenomenon. One individual in particular taught me an important lesson. She came to see me after she had been discharged from the acute psychiatric ward. She wanted to know why one of her discharge documents (she was sectioned or certified under our Mental Health Care Act at the time of her admission) indicated that she was not able to make an informed decision at the time. I am happy to say she was satisfied with my response. But my conversation with her taught me about the importance of how you treat and communicate with people. In particular, “listening to understand” and really hearing what the person is saying, as opposed to “listening to respond” and focusing on preparing a reply, helps immensely. However, this practice can only thrive in an environment that supports it.
More recently, I supported one of our district hospitals. The facility manager was concerned about staff morale. Patients were complaining about staff attitude and waiting times, and staff were feeling the brunt of their interactions with these unhappy patients in their everyday work. Staff were feeling unsafe, many not as keen to work in the hospital’s emergency center (EC) unit, where a lot of these incidents occurred. At this hospital, I facilitated a debriefing training as part of a staff support intervention.
The key principles of debriefing include that it be done in a safe space, with someone you trust, and needs to remain confidential. The debrief should discuss a work situation, with a specific focus on what emotions you experience during an incident. Over a cup of coffee or tea, the individual can be listened to uninterrupted by their debriefing buddy. Part of the training involved having participants practice both roles: debriefing and actively listening. After this session they could apply the principles and set up their own internal debriefing system.
The facility manager felt that this approach supported efforts to improve services in several ways. It helped define problems and identify the systemic issues that perpetuated them. He reported that staff felt more confident as they had more tools to their disposal when faced with difficult communication with a patient. They were able to manage the interaction with the patient much better. It also supported further quality improvement projects which led to a marked reduction in complaints from both staff and patients. For example, in one intervention, staff let patients know if they were waiting to be seen after triage that the facility would not be able to see them on that specific day by nine in the morning instead of early afternoon. Then they gave patients a referral slip to be seen the next day.
I currently do this type of work in a public psychiatric hospital providing specialized mental health services for persons with intellectual and developmental disabilities in Cape Town. I often consult with other services within the public health sector. In addition, I provide training in various other care settings, such as education and social development services. No matter where I train, the challenge I usually encounter is how to keep the momentum going after the intervention. My interest in systems theory and its application quality improvement work in health care settings helps with making these changes sustainable. I recommend that the managers or team leaders — someone who can make decisions about protocols and resources — be part of the team who receives the training. In my experience this has the bonus of creating space for team building.
Key lessons from this work include:
- Trust staff to know their context. The principles of debriefing (and the low arousal approach developed by Studio 3 in the UK) can be applied in many settings, including EC, acute psychiatry, dementia care, and education. Each setting is different, and the people who know best how to use the tools I share are the people who work there. I love learning and am often amazed at how much I learn from teams and individuals when I do an improvement project.
- Include leaders in training. Teamwork is key, and the manager of the service is an integral part of that team. If you can, train managers with their teams.
- Co-create solutions. I once came across a statement in a book that said “the brain that sees the problem usually contains the solution.” All we need to do is create an environment to support staff to get to that solution.
- Give the reins (and resources) to staff. Providing staff with the means and support to establish their own system of debriefing makes them more confident. In my experience, this leads to improved staff morale and fewer adverse incidents, and it fosters a learning environment.
- Set up a supportive environment. Time constraints are one of the most frequently cited reasons why staff find it difficult to debrief with a debriefing buddy in the workplace. But we have a choice to create this 10- to 15-minute space within the workday and reap the benefits. If we do not support staff well-being, we risk consequences, including having them off work for far more than 15 minutes.
I am constantly surprised by the resilience and innovation people show. Given the challenging context in which some of these teams and individuals sometimes work, I am amazed by the courage they display in continuing to work in difficult circumstances.
Dr. Nashareen Morris is Clinical Functional Business Unit Manager of Alexandra Psychiatric Hospital.
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IHI Africa Forum (4–6 May 2021 | Online)