Dr Peter Brown and Dr Adrian Neal

When you strip it all back, all the politics, the labels, uniforms and statistics, healthcare has many parallels to performance sport.

Within healthcare we have multidisciplinary (MDT) teams working together, problem solving quickly and using various interventions in order to maximise the probability of positive patient outcomes. In sport, we have MDTs working together to problem solve performance and use a variety of interventions in order to maximise the probability of achieving optimal performance in the moments that matter.

However, there is one significant difference between the two: the gift of the performance plan and periodisation within elite sport. Regardless of the sport and the level of competition, following any major event such as a World Cup, a world championship or the Olympic and Paralympic Games, there is always a full stop, a closing parentheses of the performance plan, a break to rest, recover, decompress biologically, socially and psychologically.

In healthcare, however, the stark difference is that there is no end, no rest, no full stop and no decompression or recovery. There may well be a period of rest and recovery for the patient but not the clinical support staff. Another significant difference is the variability and visibility around agreed objectives within healthcare; there is rarely a shared line of sight within an objective across an organisation. Objectives can change rapidly leaving little time to recalibrate an MDTs team’s shared sense of purpose or expectation of their work. What’s more, there is rarely a performance plan which factors in milestone events to support performance beyond KPIs. Instead despite delivering world class care to patients daily, the pressure only builds, the demands increase; the treadmill gets faster and the gradient steeper.

The past two years or so, since Covid officially struck within the UK, have exacerbated these ‘normal’ pressures and context. Accordingly, this three-part series of articles aims to provide:

1. A guided tour of the experience of the pandemic for individuals, teams and organisations delivering healthcare within the NHS at the Aneurin Bevan University Health Board (ABUHB) with a provocative comparison to performance sport.

2. The interdisciplinary innovative response from this health board to overcome some of this context so that we ensure performance of our healthcare staff.

3. What the future holds for the NHS in Wales and importantly the principles at play which performance sport can learn from within our novel approach to optimising performance of our healthcare workers.

The reality of burnout in healthcare provision

The Aneurin Bevan University Health Board (ABUHB) employs ~15,000 people and is the largest employer in the south east Wales county of Gwent. Approximately two thirds of these staff are patient facing, with ~600+ consultants, over 1,000 hospital and general practice doctors, 6,000 nurses, midwives, allied health professionals, health care scientists, community workers, and estates and facilities workers. All of this functions within a range of primary care provisions, five enhanced local general hospitals and a new acute care hospital. The past two years have been unprecedented within the Health Board, with the entire service provision turned on its head in 24 hours, with mass redeployment of staff to critical administration, control, coordination roles and deployment to mass vaccination clinical hubs across the county of Gwent.

The reliability of our understanding of the impact of the pandemic on the NHS workforce is rapidly improving. Initially during the first wave (March to June 2020) there was an emphasis on predicting a major mental health crisis especially around PTSD. Data from meta analyses is now rewriting this prediction even though rates of reported anxiety and depression in the workforce have risen. What has become apparent is that the impact is more diffuse and less overtly clinical in nature. Disengagement and burnout is now more of a reality and potentially a threat to performance in the NHS than diagnostic levels of mental illness, though distress is commonplace.

Burnout is categorised by the World Health Organization as a syndrome resulting from chronic workplace stress that has not been successfully managed. It is identified as having three dimensions: feelings of energy depletion or exhaustion, increased mental distance from one’s job (or feelings of negativism or cynicism related to one’s job) and reduced professional efficacy. Burnout has been linked to workplace performance since it was coined in the 1970s, however is not a new phenomenon in the NHS with pre-pandemic rates within Critical Care estimated to be as high as 20 per cent.

Measuring psychological wellbeing

Within ABUHB one attempt to measure broad psychological wellbeing has been monitored via a survey carried out five times since April 2020 and has now had over 15,000 individual responses. The survey asks about coping, fatigue, as well as factors considered foundational to psychological workplace wellbeing including one’s sense of fairness, control, effectiveness, belonging and others. Early in the pandemic the survey observed a pattern which suggested a third of the workforce were doing well, a third OK, and the remaining were struggling across all domains. Then, surveys conducted 21 months into the pandemic (July and November 2021) suggest this pattern has progressively worsened. Put simply, we are seeing data to suggest that at least half of our workforce are experiencing psychological difficulties and are also relating to their work and peer groups differently. Many report feeling the work they loved has changed, that they feel like they no longer make a difference, are demotivated as a result and, importantly, that they do not feel connected to or a part of the wider organisation.

This data and lived experience represents a major threat to the organisation given NHS services often rely excessively on a workforce with high intrinsic motivation, willing to offer extra discretionary effort to function let alone high performance, or any performance unremittingly.

Comparing performance measures in healthcare and sport

From a human factor perspective, the pandemic inevitably has and will continue to have an impact on NHS performance on an individual, team and organisational level, however an artifact of how performance is commonly framed in the NHS may make it even more challenging and requires closer examination especially when you juxtapose to elite sport.

When it comes to the performance and performance outcomes of performance support staff and athletes, elite sport have excelled in contrast with healthcare. Within sport there is normally a clear alignment between performance outcomes and capability of the athlete(s) and / or the service provision provided by the performance support team due to the investment and robustness of the performance plan and multidisciplinary dissection of performance through a performance backwards approach. In healthcare, it’s a little less clear with a lack of agreed and shared objectives across organisations and teams.

Table 1 below provides an example of the comparison of definitions and measurements of performance between healthcare and elite sport.

Table 1. Comparison of performance measures in healthcare and sport.

Within healthcare, there is the obsession with key performance indicators (KPIs) which, in turn, are politicised performance targets rather than outcome focused measures of success. Performance management in healthcare is failing to measure performance and succeeding in gaming the data to achieve a given (sometimes malevolent) purpose.

Within all aspects of health and social care, we currently have a perfect storm. Rising waiting lists, greater than ever patient acuity, Covid restrictions, mass redeployment of staff from all corners of the organisation to support vaccination centers, rising staff absence, hundreds of patients clinically ready to be discharged to community but without the necessary support to leave the hospital and the numbers waiting for referrals, diagnostic tests, therapies and treatments on the rise.

The Welsh government have provided several hundred million pounds of additional funding across Wales to support the recovery from the pandemic, but the pandemic continues with wave after wave of mutated variant which doesn’t align to financial years. At 8pm every Thursday throughout the lockdown of wave one of the pandemic in the UK, the general public stood on their door steps and applauded the NHS workers and the windows of family homes were smudged with the finger prints of children who proudly displayed their paintings of rainbows to support the NHS and key workers. It feels like those days are gone. We now face increasingly high expectations from the public and government alike.

But it’s not all doom and gloom and our next instalment of this series describes how through a close collaboration of Organisational Development and Organisational Wellbeing / Clinical Psychology at the ABUHB, we are truly embracing the complexity of the situation we find ourselves in to address the key performance issues affecting our workforce. At least for us on the ground, moving away from arbitrary performance outcomes, numbers and dashboards to truly defining and understanding where we are today individually as teams and as an origination, the counterfactuals of our situation, and the adjacent possible to move towards a better future.

Dr Brown is Director of Organisational Development (OD) at the Aneurin Bevan University Health Board (ABUHB) in South Wales and spent 10 years as the Head of Performance Knowledge at the English Institute of Sport.

Dr Neal is a Consultant Clinical Psychologist and Head of Wellbeing at the ABUHB and has researched and published widely across organisational health and wellbeing.

1] Aneurin Bevan University Health Board; see abuhb.nhs.wales

[2] UK Sport; see uksport.gov.uk

[3] Performance to Paris: GB Boxing Strategy 2021 to 2025; see gbboxing.org.uk

[4] Olympic medal target for the Tokyo Games

By John Portch

• A carefully calibrated facility can attract the best talent in a crowded market

• Consider your athletes’ major staffing touchpoints and use them to your advantage

• Future-proof your building – be wary of designing a space for a specific use

The starting point is people and culture

So says San Antonio Spurs Head Coach Gregg Popovich. ‘Coach Pop’ caught wind of the organisation’s wish to create a new practice facility and approached Phil Cullen, the team’s Director of Basketball Operations & Innovation on the gym floor. “He goes: ‘I’ve got two things for you: protect the culture and protect the people’,” Cullen later told an audience at November’s Leaders Sport Performance Summit in London. The Spurs have since broken ground on their new facility. “When we talk about design, we talk about influences on design, the human-centredness. It was an approach he really took from day one.”

If you’re building a new facility, be sure your architect listens

Cullen explains that San Antonio had an issue with sports-focused architects whom they consulted. “They try to give you the best rendition of what they’ve just completed,” he said. “They’ll kind of tell you what you want rather than really listening to what you need.” The solution was to partner with an architect that had experience of other sectors. “All of us now are becoming small tech companies; the technology’s integrated in everything we do. Why aren’t we looking at technology companies and how they work to see how it can impact how we’ll work in the future?” The Spurs were left considering aspects and thinking points they may not have otherwise considered.

Who are your athletes’ major touchpoints?

Human-centred design promotes the casual collisions that promote collaboration and creativity. “A lot of times it’s focused on the coaching element, which is extremely important, and player amenities, but how do you facilitate those casual collisions?” said Cullen. “The people that would be in your facility the most and have the most touchpoints are probably not who you think they are. For us, it was our equipment guy. Very often you’ll go back and the players are hanging out with the equipment guy. Why? Because they can just hang out. It’ll be the athletic trainer, it’ll be the guy who’s taping his ankles and helping the guy rehab.” This has been uppermost in the Spurs’ thinking, who have even installed TVs close to the ceiling of their current facility to help take players eyes away from their phones.

Cullen added: “How can we make sure we have the best possible experience so that we’re actually giving them opportunities in their career development; giving them all the resources they want to advance? So that when we go into the marketplace to recruit these guys to have elite talent in our building, we’re not only attracting elite basketball players and elite coaches, but also the staff around them. That’s where collaboration is key. For us, the human-centred design piece is really trying to break down those interactions and it starts when the players pull up into the facility; what’s that experience when they enter in, get out, walk into the parking lot? Who are they walking past when they go to the locker room?”

Future-proof your facility – leave some space free

It can be tempting to throw the kitchen sink at a new facility but the Spurs and Cullen are wary of doing so or being locked into one type of technology. “We’re trying to be intentional about not designing a space for one specific use because it can very quickly become a closet if it can’t be used for more than one thing,” he said. “By far the No 1 thing people tell us is make sure you have enough space. You may not have all the nice designs and be able to finish it all out, be able to brand it, be able to story-tell the way you want, but make sure you get the space because you want to future-proof and you can’t move around in it.”

Recommended reading

How Your Training Sessions Can Better Promote Athlete Learning

The State of Play Series: Coaching the Modern Athlete

The Power of Coaching Cues

Framing the topic

An interesting thread of discussion amongst our Leaders Performance Institute members has been evolutions in the daily coaching environment, particularly pertaining to session design. The reasons for this stem from the need to create stimulating sessions for the modern athlete or learner. During this virtual roundtable, we explored some of the focuses across different environments.

Discussion points

What are some of the things you are prioritising in relation to your current culture and why?

• We are heavily looking at athlete empowerment. Within the training week, with some constraints, we have allowed the athletes to choose what they want to do on that particular day. The coaches provided some structure which aligned to the wider programme they are working towards, however the manner in which they achieve those outcomes and the makeup of skill elements was left up to the athlete.
• Considerations for coaches were: will the athletes pick the easy option? It was trialled over a six-week period and we did find that it helped support creativity, a number of the athletes chose things that we wouldn’t necessarily have pigeon-holed for them and it created good conversations. Athletes did also seem to enjoy those sessions a bit more during the week. A question moving forward is whether this should be strategised as part of the wider session design.
• Co-designing sessions with athletes carries a lot of merit. Providing constraints and allowing conversations to extend from there worked well, it also allowed for collaboration around sessions the following week.
• Some of the trends from this trial were that some of the less-dedicated athletes chose easier practices than the coaches would typically have picked for them. The athletes who are more dedicated and self-reliant on the whole chose what the coaches would have selected for them. Over time, the athletes who chose easier practices moved up to a level where the coach would have wanted them to be. It was also interesting to see younger athletes pick harder activities with a higher skill level which they weren’t ready for, but it generated interesting conversations for the coaches. A challenging process for the coaches was to not judge too much and let the choices just materialise.
• Anecdotally within the coaching sphere, a lot of coaches and teams are looking at providing more athlete ownership and exploring ideas around this, but are trying to work out how to do it and what the trade-offs are. There’s certainly a quest for co-design and co-construction.
• A good question for coaches to ask themselves is ‘what is the reason why we are doing this type of practice design?’ Often it will align to the athletes taking more ownership of their training (self-determination theory of motivation), which increases the knowledge base of the athlete. A lot of sports have been coach-driven for a long time, which has led to some real negative impacts – changing the culture of the authoritarian coach, whilst also helping to support and develop athletes for life through different life skills.
• An interesting observation from our coaching environment when moving away from a coach-led environment was that a lot of the athletes were lost and weren’t sure what to do. This is an interesting challenge for coaches in how to support them if you are considering this change. We saw friction between what the players wanted in terms of their own style of play in the sessions and preparing for the opponents’ style. A question we asked is how much of your own style is too much?
• Our club from 1st team level down to the Under 18s has a playbook – it’s focused on the ‘pressing style’ of the team. There’s definitely a balance to be had around your own style, but then finding problem-solving scenarios with how the opposition will set up.
• Within the pathway, it’s much more of a problem-solving mentality. We have co-coaches within our curriculum. If we are focused on a specific part of play, one coach will focus on that, whilst the other works on the counter elements. This has been very successful, but the part we are wrestling with is how aligned is it to how we will play on a match day (the counter elements designed by the co-coach maybe different to how the opposition play).
• Keeping athletes aligned and part of the solution is hugely impactful. If coaches believe in a certain way to positively influence a game-scenario but the players don’t believe in it or feel a part of the process, they won’t commit to the full extent they might do. Ownership and empowerment comes from ideas they put forward. Previously we used to just use the senior pros, but it has now been opened up to the whole squad. It’s important as coaches to remember that we have to meet the athletes where they are.
• What should we do as coaches with the athletes who aren’t too bothered about taking ownership? Do we force them to engage in this way or do we let them engage in the way they want to? We were hoping there would be some social calibration of behaviours but it hasn’t materialised as we would have thought.
• Something to be aware of with player ownership and, in particular, leadership groups, is that they don’t become a militant group where they hammer people – if coaches give players the ownership to take more responsibility it can’t swing so far the other way that it creates a toxic environment. Player empowerment can’t swing so far that the coach then can’t do anything without the say-so of the athlete group – it’s proving really complex for coaching at the elite end of the game. When does empowerment lead to entitlement and control?
• We are about to witness a sea-change in terms of our environment as we are evolving the physical training environment – there’s going to be a lot of change for the players, so how we as coaches are managing that is important. We’re looking at identifying leaders within the group to support with this transition.
• We’ve spent some time looking at player engagement and what they want from a session. We got the players to draw up sessions and then we looked for the trends. All of the sessions had elements such as goals, finishing, opposition etc. Around 80 percent revolved around the individual or person and how they could get success or how they could work on particular aspects of their game or a ‘super-strength’.
• Within our individual development plans, we have put them into moments in the game – moments they really thrive at or need to improve at. In practices we now make it relevant to the curriculum, it will always have goals, opposition and will be explicitly stressed before the session ‘this is how we are working on your plan within this session’ to each player. We are making individual development plans more game-based with ‘add-ins’ from the coaches. One of our former members of staff told us how Disney used to have a concept where you had to add – it’s easy to feedback and criticise, but what would you add to make it better?
• In terms of other evolutions within our session design and practice, we are increasing the use of video – it is integrated into the daily training environment. If it is a practice where the athlete is not being heavily coached and instead the athletes are watching themselves, they can relay their kinaesthetic feelings with what they can see with their eyes. If it is a technical session, the coaches can coach through the video as well.