Team-based support

The observed importance of informal support reflects recent studies involving health and social care professionals during COVID-19.^{Reference Brooks, Webster, Smith, Woodland, Wessely and Greenberg3} Subsequent recommendations for supporting healthcare staff through COVID-19 include harnessing team- and peer-based support by upskilling supervisors to spot early signs of distress, ‘buddying up’ junior and experienced team members, and ensuring that structured peer support is available for staff, such as critical incident staff support.^{Reference Greenberg and Tracy4} These recommendations are based on the principles of proximity, immediacy, expectancy and simplicity (PIES), which enable staff to continue working where possible and ensure that they are supported before their distress escalates into crisis. Informal support can also ‘de-medicalise’ distress by emphasising strengths-building and coping and moderating the impact of stigma on help-seeking for mental health issues.^{Reference Johnson, Hall, Berzins, Baker, Melling and Thompson5} Research supporting the effectiveness of such interventions has typically been conducted on military populations.^{Reference Solomon, Shklar and Mikulincer8} A rapid review of healthcare well-being interventions provides support for whole-systems and group-based interventions as preventive measures, although greater quality of evidence is desired.^{Reference Bajorek and Holmes9}

Existing interventions for staff well-being incorporate elements of peer support. For example, reflective practice groups are often embedded in clinical practice, enabling staff to discuss the emotional impact of their work and receive support within their teams.^{Reference O'Neill, Johnson and Mandela10} Similarly, Schwartz rounds allow staff to share emotional experiences with others from across the organisation and have been widely adopted by NHS trusts.^{Reference Taylor, Xyrichis, Leamy, Reynolds and Maben11} One review of these interventions including 41 studies found that staff reported improved well-being and coping, job satisfaction, teamwork and empathy for colleagues as a result of these spaces.^{Reference Taylor, Xyrichis, Leamy, Reynolds and Maben11} The continuation of such spaces therefore remains an integral part of staff support provision. At SLaM, findings in this evaluation led to ‘team well-being plans’ being developed and distributed as a means of encouraging collective problem-solving and to support team well-being in the longer term.

Barriers to effective team-based support

Our findings indicate that pressures on managers, discrimination at work and remote working were perceived as key barriers to accessible and effective team-based support in the context of the emerging COVID-19 pandemic.

Organisational pressures can put strain on team leaders, which may cause them to be controlling or unsympathetic towards team members and be less likely to act with integrity or provide adequate support.^{Reference Braun and Clarke6} Staff well-being may therefore benefit from leaders being appropriately trained to support staff and themselves,^{Reference Stuber, Seifried-Dübon, Rieger, Gündel, Ruhle and Zipfel12} particularly in the contexts of organisational change or services under pressure during COVID-19. Team-leader training is now being more widely integrated into the staff support provision of SLaM, aiming to improve leaders’ understanding of burnout and workplace stress and help them to look after themselves. Additionally, the sessions aim to upskill managers to have conversations about well-being using active listening skills and to improve their awareness of available support services, which can be disseminated to colleagues.^{Reference Akhanemhe, Wallbank and Greenberg13}

The experiences of racism and discrimination reported in our findings, are known to add to workplace stress and to have an impact on confidence in workplace support mechanisms.^{Reference Rhead, Chui, Bakolis, Gazard, Harwood and MacCrimmon14} Surveys of NHS staff have previously reported that staff from marginalised groups receive higher rates of abuse and bullying than White colleagues and perceive fewer opportunities for career progression.¹⁵ Employers need to go beyond listening and data gathering to provide evidence of action towards racial equality, for example working with human resources departments to change recruitment processes and the transparency of career progression pathways.^{Reference McGregor-Smith16} Cultural competency training is currently implemented across NHS trusts, aiming to challenge prejudices towards marginalised groups by improving cultural awareness. However, cultural knowledge does not necessarily lead to a reduction in discriminatory behaviour, and such training may reinforce negative beliefs and practices by homogenising marginalised groups.^{Reference Kowal, Franklin and Paradies17} This may point to the need for organisations to adopt novel approaches that advocate ongoing individual reflexivity on personal beliefs and prejudices.^{Reference Bhui, Warfa, Edonya, McKenzie and Bhugra18} Teams may benefit especially from organisations providing such training for team leaders, given the crucial role leaders have in supporting marginalised staff. Continuing to acknowledge the wider prevalence and impact of racial discrimination and changes to public narratives may also be important in supporting staff. There is an expectation of employers to be engaged with politics and take a stance on societal issues.¹⁹ Employees’ perceptions of corporate social responsibility, and organisational justice, are associated with employees’ sense of belongingness, meaningful work, job satisfaction and retention.^{Reference Bauman and Skitka20,Reference Nimmo21}

There is currently a paucity of research into team-based support and well-being in remote-working teams, although concerns about social isolation and sense of belongingness in newly made remote teams have been acknowledged during the pandemic.^{Reference Rubin, Nikolaeva, Nello-Deakin and te Brömmelstroet22} Remote workers may benefit from using online platforms to replace informal conversations, allowing staff to discuss challenges, gain practical tips from co-workers and evaluate their performance after a difficult piece of work.^{Reference Hafermalz and Riemer23} Such platforms could be used alongside similar methods used by our participants to stay connected with colleagues to improve access to social and practical support in these teams. Further work is likely necessary to understand concerns about remote working now that this practice has become a ‘new normal’ for many and as lockdown restrictions ease, allowing individuals to see family and friends again and enabling more flexibility in working practices. Employers in the future may provide staff with greater choice regarding remote or on-site working,^{Reference Hardman, Llewellyn and Walker24} which could improve access to team-based support for those on-site or create new challenges for team cohesiveness. Research into this area will be particularly important as flexible and remote working become more commonplace in the NHS.

In addition to implications for support service delivery, the collection of data from existing staff forums illustrates a swift method of gathering qualitative data from large workforces. Given the time constraints and limited capacity of healthcare workers, existing meetings and forums can be used as sources of rich and nuanced qualitative data where repeated issues and challenges are discussed. In circumstances where information is needed promptly, accessing existing spaces is a mode of consultation not requiring an additional time commitment from participants.

Strengths and limitations

Although many interview respondents were facilitators of support spaces, the majority were working remotely, which may have affected their ability to reflect on experiences of staff on-site. Additionally, knowledge of available support will have affected their responses. Our conclusions may therefore be unrepresentative of staff who ‘fall through the gaps’ and do not access workplace support. Future studies should look to recruit from more workforces with varying engagement with staff support. Data source triangulation from interviews and staff forums support the validity of findings.^{Reference Carter, Bryant-Lukosius, DiCenso, Blythe and Neville25} Our research team was made up of SLaM staff who therefore held ‘insider status’ and were keen for the findings to inform the iterative development of support offered to staff. This allowed focus group facilitators to have a good contextual understanding of the perspectives shared by staff, aligning with the interpretive phenomenological framework, but may have affected the approach to thematic analysis. S.Z. and S.D., whose roles are clinical and not directly involved in staff support provision within the trust, supported the confirmability and validity of findings through investigator triangulation.^{Reference Cohen and Crabtree26} Pre-pandemic, there is evidence of higher workplace stress in mental healthcare compared with physical healthcare settings;²⁷ however, it is likely that our findings also apply to staff in other healthcare settings, particularly where results reflect previous research.