In our first piece, we described the context of operational delivery throughout the pandemic and the effect this has had and continues to have upon the workforce. We then provided comparisons between healthcare and performance sport, specifically in relation to performance plans and outcomes.
Then, for our second piece, we then moved on to present the opportunity for innovation within a crisis and the role of leadership within this to create the time, space and options for to enable novelty to emerge drawing upon the theoretical frameworks of complexity science and drive theory.
This final instalment wraps up our series by describing the potential route out of the pandemic in healthcare, or as is frequently coined, the ‘recovery’ from the pandemic. We will describe the new norm and the timescale and context of what recovery looks like for us and, importantly, the potential learning for and from performance sport.
Recovery: the impossible utopia for healthcare
There are many parallels between healthcare and performance sport, although one major point of difference is the ability for the performer and their support team to recover after training and performance.
In the recent Tokyo Olympic Games, teams were encouraged to decompress, which provides a time and space to adjust to a more relaxed state after the biopsychosocial stress of the event allowing the processing and acceptance of both positive / negative feelings and experiences to minimise maladaptive adjustments.
In healthcare, either on an individual level or an organisational level, recovery is not operationalised as an essential component of the performance cycle which might support biopsychosocial adaptation for sustainability. Instead, National Health Service [NHS] systems and the individuals within them are faced with a renewal of demands e.g.: political pressure to resume services and meet targets, public pressure to meet needs and address an increased acuity of patients linked to services not being accessible during the pandemic, budgets restrictions and, in some cases, cuts, the need to continue to provide Covid-related services, and increased staff absence and turnover.
The demands are relentless, leaving little space for recovery as a concept or as an essential component of sustainability and performance. Recent survey data from our Health Board demonstrate that significant numbers (>50%) of staff are physically and psychologically exhausted from the pandemic and are worried about how they can continue. In the eyes of many this situation represents a dichotomy, both an existential threat to the NHS but also an opportunity to motivate a system to change. Change the system to enable recovery of the people and the organisation, which may slow down services, or carry on as we are and risk staff leaving the profession, which creates even more disruption both fiscal and patient facing.
What we also know is that offering NHS workers a greater opportunity to have a positive experience of work is now an organisational priority. If we can help them do the work they have trained to do with purpose, reduce avoidable harm created through our processes, and at the same time help them feel like they are valued, we will have made radical progress – and desired ‘performance’ outcomes will increase.
From healthcare worker to healthcare performer
When considering the consistent demands placed upon healthcare workers, whether this be the porters and domestic staff preforming up to 30,000 steps per day, or the intense cognitive capacity required by surgeons to perform prolonged procedures, or the emotional demands faced by staff regularly exposed to distressed patients and demanding concerned relatives, maybe it’s time to reframe how we conceptualized this work.
Perhaps we should reframe healthcare staff as ‘performers’ not workers. When considering the athlete approach to performance in any given discipline, it considers the performance plan (see Part I) and the outcome ambitions that create focus, we consider the multidisciplinary performance science teams which surround the athlete planning. Then, we can adjust the environment for optimal training, including coaching, nutrition, sleep, mental preparedness and much more. Critically, this process revolves around optimising the athlete’s ability to be available to perform, to exert the appropriate effort in context and to recover, be ready to go again when it matters and, ultimately, to achieve the agreed and often very clear goals (i.e.: medals or improvements on previous performance).
There is little of this process present in healthcare. We have staff who regularly work 12+ hour shifts (in spite of evidence stating this is detrimental to their health), surrounded by poor quality nutrition, sometimes limited managerial and leadership support, often with insufficient staffing levels. Paradoxically this combination of factors almost guarantees high or sustained performance is not possible. If we consider the healthcare performer, we will need to re-engineer huge parts of the healthcare system, but perhaps now is the moment to do so.
A possible way forward might be to, rather than focusing on arbitrary goals or key performance indicators which are externally generated and often inherently political and perversely promote gamification and minimise intrinsic motivation/discretional effort, we focus on clear mutually agreed objectives in the present, and use this to shape how we optimise performance today, this week, this month.
We support this by co-creating meaningful performance measures which reflect the work being done by the people doing the work, and have a strong link to their sense of purpose and moral justice. If we focus on these factors within healthcare, as in the educational sector, for example, to be intrinsically motivated, their work has to give them meaning to be validating thus rewarding and internally motivating.
An irony within healthcare is that we know through research that many of the stressors faced by the workforce are not necessarily due to the work itself (primary stressors) but rather factors classed as secondary stressors (e.g.: bureaucracy without overt meaning, formal processes, management / leadership capability, psychological safety, inadequate job descriptions or role clarity). Left unchecked, many of these secondary stressors will have a negative impact on wellbeing and performance and have the added potential of creating unintentional harm to both individuals, teams and the organisation itself.
Changing both the narrative (workers as performers) as well as re-engineering the structures that are in place that maintains the identified performance inhibiting dysfunction is easier said than done clearly in the public funded healthcare sector, especially our Health Board which has nearly 15,000 employees. Notwithstanding this, there remains a pandemic-generated window of opportunity where we might be able use ‘recovery’ as a platform to initiate some of the changes we have highlighted and examine the way we support and develop our people, because we very much need to do it differently to enable the people of the NHS to thrive.
This message also serves as a call to arms for performance leaders in sport: are you providing an environment which enables your athletes to thrive, providing co-created measures of performance markers, with a strong focus on their internal sense of purpose, their sense of meaning gained from being an athlete and moral justice and not just the quantifiable performance per se (being mindful that the opposite of these psychological components being burnout)?
To bring together, our thoughts over this series of papers bringing together Organisational Development and Clinical and Organisational Psychology in a novel way, we are determined at the Aneurin Bevan University Health Bored to be different, to disrupt for a better future. What’s more, together between sport and healthcare, there is much we can learn together in order to create something which is compelling and will move the future of sport and healthcare to the next level.
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.
In our first article, we described the context of operational delivery over the past two years of the pandemic, the effect this has had, and continues to have, upon the workforce in healthcare and the comparisons between healthcare and performance sport: specifically in relation to performance plans and outcomes.
The pandemic continues to have a significant impact upon the delivery of all NHS services in Wales and across the UK. Most services (clinical and corporate) are feeling the exhaustive pressure of increased demand for clinical services, disrupted service models, record levels of staff absence (linked to sickness or self-isolation) and the weariness associated with responding to the recent Covid surges.
However, like many disruptive forces it has also given opportunities for innovation and creativity and this instalment of our three-part series explores the key opportunities for innovation within the ABUHB in response to the pandemic.
The leader’s choice within a crisis
Without using the phrase lightly, the NHS is operating within a crisis. As an organisation, many of our clinical and administrative teams have been redeployed from their normal roles to mass vaccination clinics and/or to help on wards with various tasks. We’ve been pulled from pillar to post both metaphorically and often literally. But despite this context, there is a choice to be made by leaders. Do you a) roll over and admit defeat or b) use it to your advantage and harness the opportunity a crisis brings. In the ABUHB Organisational Development and Wellbeing Teams, we’ve stood up to this disruptive force, looked it square in the eyes and chosen to use it to our advantage and innovate.
When working in a crisis, it’s no good doing the same old things in the same old ways. You need to be able to flex, adapt, and evolve to the situation.
Two key theoretical frameworks have supported and enabled our thinking during this: i) complex adaptive systems and ii) Three Motivation System model[1]. What is fascinating is that the optimal way to function in a crisis and complexity according to complexity science is somewhat opposite to people’s and organisation’s natural autonomic response. Complex adaptive systems present us a novel lens of making sense of our environment in order to act within it. Specifically using the Cynefin framework which is part of the naturalising school of sensemaking tools, we know that we operate within one, multiple, or the liminal spaces of multiple systems. These systems may be ordered where cause and effect are linear, known and repeatable with robust or governing constraints; complex where cause and effect are only known in retrospect and enabling constraints are present and, lastly, chaos, where there are no effective constraints.
By knowing the system you are in at a given time and the relative distance from the other systems by understanding the constraints of your environment, you create coherence enabling your leaders, people and the organisation to act with maximal understanding and minimal energy cost.
Innovation within a crisis
Our present situation in this pandemic throws the NHS well and truly into chaos where there are (at times) no effective constraints. The absence of constraints has enabled us to act and try new ideas shifting us from a system of chaos to one of complexity. For leaders, this can be worrying and energy-sapping, on the other hand, it’s also liberating. The absence of constraints makes innovation possible, it allows ideas to emerge rapidly, for us to learn through self-organisation, rapidly adjust to our environment and to navigate our world by maximising our contextual understanding. It allows us to create some form of coherence within our system and nudge it back to a space where we have elements of control. Within ABUHB we have taken advantage of this creating several game changing interventions such as:
Linking motivation with complex systems
The second key theoretical paradigm shaping our work is Three Motivation System model (Gilbert, 2009). This evolutionary psychology model identifies that humans self-regulate their emotions (their autonomic nervous system) in three distinct ways;
i) by initiating a threat response and rallying social and intrapersonal defences;
ii) harnessing action or drive such as by focusing on detail, being productive and trying to exert control over the environment;
and iii) by soothing via meaningful contact with others or relying on one’s own internal recourses.
For people, this model supports evidenced-based psychological treatments for a range of mental health difficulties (e.g.: types of eating disorder, depression, shame, perfectionism, and psychological trauma). However this theory also has powerful relevance when applied to an organisational or system context. For example we can see how the two most common (and least adaptive) motivations manifest as omnipresent behaviours within an organisation such as the NHS i.e. the compulsion for increased control (grip) through detail and increased bureauocracy and social aggression (bullying, passive aggression and territoriality) which are in opposition to the naturalising sensemaking approach where the constraints of the system govern behaviour, not the other way around. This may also present in performance sport such as in the high performance training environment, the construction of performance plans or in the lead up to a major event.
Motivation, psychology and innovation
Emerging from a crisis, in the context of our people, the Three Motivation System model suggests that innovations that can be used to increase the frequency and quality of prosocial (soothing) interactions will help both individuals and systems to regulate their emotional states – leading to more prosocial behaviour, increased productivity and psychologically safer working environments. What’s more, this model encourages us to better understand the core conditions that allow humans to thrive, which has in our context led to the development of our Employee Experience Framework with its six core conditions focusing on peoples sense of: control, feeling cared for, purpose, fairness, belonging, and having value (most of which are determined by social context and culture).
We are now starting to see how the Three Motivation System model and naturalising sensemaking can help us shape our organisational recovery plans, by identifying the working conditions that will promote the most positive and adaptive means for our workforce to start to recover from the unprecedented biopsychosocial demand of the past two years and navigate the challenges to come.
For leaders in performance sport, knowing the system(s) which you are operating within at a given time and the psychological frameworks underpinning and governing the organisation and the people that operate within it, you can begin to apply the right nudges to people, processes and behaviours to accelerate performance through innovation at an individual, team, organisational and system-wide level to create the right conditions for the emergence of the outcomes we believe are favourable.
Table 1 describes some of the innovations we within the Aneurin Bevan University Health Board have begun since the pandemic hit using these frameworks.
| Area of Innovation | Challenge to address | Progress |
| Promote optimal working conditions to ‘Thrive’ using the Employee Experience Framework. | Working cultures that are threat based – focused on performance and control, with limited understanding of human motivation in a professional caring setting. | Promoting a work environment that supports ‘thriving’ will become our number one objective, our north star. |
| Evidence-based recovery planning | The need to help the organisation understand the impact of the pandemic on the workforce and which human factors are necessary for it to recover its capacity to meet the health needs of the public. | In development, this strategy will form the backbone of our short, medium and long term planning. |
| #PeopleFirst #CynnalCynefin
(Welsh phrase meaning: to reconnect with self and others in your multiple places of belonging) |
Workforce disengagement, over-reliance on centralised decision making and loss of trust in local leadership. Lack of personal agency and control. | Organisation wide project using naturalising sensemaking methods to understand the current state of all staff and shift to a better future defined by them not us. |
| Post-pandemic Clinical Leadership | There is a real need to develop new ways of selecting, developing, and sustaining our clinical leaders and triumvirates. | Existing formal leadership development opportunities are being reviewed and redesigned in light of the pandemic learning. |
| Increased opportunity for meaningful social interaction.
|
The pandemic has increased the sense of separateness at work via the physical restrictions of infection control but also due to dislocated staff groups and home working. | A rolling programme of social interventions (e.g.: Schwartz Rounds, anecdote circles) have been initiated. |
Summary
In summary, both complex adaptive systems and the Three Motivation System model provide an evidence-based theoretical frameworks that might allow an NHS organisation and performance sport, it’s people and networks to thrive. At Aneurin Bevan University Health Board, we are pushing the boundaries in these areas unlike any other NHS organisation. In the context of the NHS, and perhaps some elite sports functions, we also must hold in mind the magnitude of the ambition; to help an organisation recover in the least maladaptive way following a period of unprecedented chronic crises, especially since the situation was already fragile before March 2020.
In many ways, what we are endeavouring to do is radical but is borne out of a realisation that change is vital for sustainability, possibly even survival. It is perhaps apt that we are drawing upon a psychological model from evolutionary psychology literature and models of sensemaking from the natural sciences. We need to evolve to survive and to do so will require a degree of transformational thinking, while also being fully aware that the delivery of essential services cannot at any time stop.
We ask this question to leaders across sport: how much of what you do is the same now as 1, 5 or 10+ years ago? How may you be able to use the models suggested here to at least review and think about what’s possible? This may be radical change, or subtle shifts to the adjacent possible; what is the current state and the most plausible next step to take for change. To what extent is doing what you always have done self-perpetuating and missing significant emergence of factors which could be game changing for you and your athletes?
Our intension is clear, there is no fixed pre-determined or prescribed destination or goal, rather a well thought out direction of travel to allow us to discover new and emergent things along the way. This approach makes most NHS veteran managers, high performance coaches and directors deeply uncomfortable and may well trigger their drive and / or threat responses. We are however certain that the transformation we seek cannot be achieved by a linear task and finish approach alone with rigid constraints, to do so would risk missing vital context and emergent opportunities to learn and simply be a re-enacting of past maladaptive patterns which only service to meet short term and emotionally driven motivations, i.e.: to allow us to feel less anxiety for a short time.
In our third and final edition of this three-part series, we explore what’s next for healthcare as we begin to emerge out of this crisis, what scares has been left behind as an organisation and on its people and finally the parallels between recovery in healthcare and performance sport.
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] Turner et al. Systems, 2022
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.
| Healthcare[1] | UK Sport[2] | NGB (GB Boxing)[3] | |
| Mission | Reduce health inequality experienced by our communities by improving population health, this mission will vary significantly between NHS organisation, department and team. | Create the greatest decade of extraordinary sporting moments; reaching, inspiring and uniting the nation | To build the world’s best performance system enabling each GB boxer to very best opportunity to reach their full potential. |
| Paraphrased ambitions / Priorities | Every Child has the best start in life | Keep winning and win well | Performance focused |
| Getting it right for children and young adults | Grow a thriving sporting system | Coach-led | |
| Adults in Gwent live healthily and well | Inspire positive change | Boxer centered | |
| Older adults are supported to live well and independently | Open and competitive | ||
| Dying well as a part of life | One team | ||
| Typical Key Performance Indicators | Waiting times – National and local KPIs vary: e.g.: Emergency Department, Psychological therapies, specific operations, HR processes. | Investing £385m in 57 sports for success in Paris and beyond | 3 to 5 medals at the Paris Games |
| Errors | 10 World championships | An Olympic champion at Paris 2024 | |
| Financial KPIs | 30 European and World Series events in more than 25 sports | Male and Female world champion by 2024 | |
| Complaints – response times | Generate £70m of economic impact | Elite boxers to lead the medal table at the commonwealth games | |
| Number of Vaccinations delivered for Covid-19 | Medal target 45 to 70 medals[4] | Medals at every major championship throughout the cycle |
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
