ICATA Journal
‘A Space to Think and Connect’ A Team Wellbeing Initiative in the thick of the COVID-19 Pandemic
Cite as: Bonfield, S., & Davies, J. (2023). “A Space to Think and Connect” A Team Wellbeing Initiative in the thick of the COVID-19 Pandemic. International Journal of Cognitive Analytic Therapy and Relational Mental Health, 5(1), 115-129. https://www.internationalcat.org/volume-5-7
Int. Journal of CAT & RMH Vol. 5, 2023 / ISSN2059-9919
Abstract
‘A Space to Think and Connect’ was a wellbeing initiative developed in response to the COVID-19 pandemic. The initiative was created to provide teams working in a public health service with the opportunity to come together to talk about (feel and process) the impact of the pandemic on their work and working relationships. This wellbeing initiative drew upon the existing evidence-base for supportive early intervention for people exposed to trauma, or potentially traumatic events (Richins, et al., 2019) and the rapid guidance developed during the early phase of the pandemic on psychological help for people working in healthcare (traumagroup.org; kingsfund.org.au) which highlighted the need for peer support programmes as forums that focused on talking about emotional and social challenges related to working in healthcare during COVID-19. Our practical focus was on team cohesion (Greenberg, 2020; Billings, et al., 2020) and what we thought was needed, and would be backed within our system.
As the name suggests, a key purpose of the initiative was to provide ‘protected’ thinking time that allowed teams to take time out from the tasks of their roles and focus on how they were working together at a time of increased stress and pressure. We wanted the groups to be more process driven than solution focused and to create relational awareness by holding open a space for meaningful conversation of experiences with mixed views tolerated, and themes and patterns identified. It aimed to provide a space for feelings to be heard, acknowledged, and processed together with colleagues working within the same system who ‘understood enough’ of each other’s worlds to catch on and connect. It was an opportunity to connect with colleagues and feel less alone and more ‘together’ (Figure 1). How this initiative was run is described in this paper, including the pilot measure used to try to capture relational awareness and qualitative feedback. It tells the story of what we did at a time of personal and organisational and societal crisis and offers some evaluative data.
Background
During the early phase of the pandemic, literature reported on the psychological impact of the pandemic on the mental health of healthcare workers (Greenberg, et al., 2020; Greene, et al., 2021) and the need for early intervention to enhance coping and provide needed support given increased risk of experiencing work-related stress, burnout and general mental health problems (Chana, et al., 2015; Howgego, et al., 2005).
As it did all over the world, the COVID-19 pandemic had widespread impact in Melbourne, Victoria, Australia, and we experienced some challenging restricted measures. Many people were personally affected (lockdowns, home schooling, job losses etc.) as well as professionally impacted (in relation to public health this meant redeployment, frequent protocol changes, COVID-19 contagion and much more). When trauma and adversity occurs at a community and collective level, it is known to have widespread impact including a sense of disconnection within and between groups, pervasive fear, and lack of security and safety (Treisman, 2021). Whilst we are not saying that everyone experienced COVID-19 as ‘traumatic’, the widespread impact meant that most were impacted in some way in our local community. Working in public health at the time added an extra layer of impact, as feelings of fear were around within the system – as one participant said, ‘it’s in the air’. Responding to this was a complex relational task as many individuals were coping personally on top of having to navigate the push and pull of feelings of colleagues also under stress and absorbing the ‘fear’ within the broader systems of work and community. Within the workplace specifically there was a disruption to familiar professional narratives and teams and the broader system operating in survival mode and more narrow ways of relating and coping as an understandable consequence.
In specific relation to the pandemic, Greenberg, et al., (2020) spoke about how group discussions had an important role in helping people develop a meaningful narrative (or shared story) and that this was a protective factor against the challenges experienced by healthcare workers. Peer group processes are also known to have a supportive function for teams, strengthening camaraderie and protecting against the long-term impact of stressful and traumatic experiences (Richins, et al., 2019).
Purpose
We wanted to create an early intervention, ‘workforce wellbeing’ initiative that built upon peer group processes and the strength of teams to support each other, through having relationally aware conversations that enhanced connection, helped shared meaning making, and provided a place for feelings. We drew upon Potter’s (2022) description: ‘Relational awareness is the awareness of patterns of interaction that happen within us, between us and around us and which we achieve, or limit, together by sharing and negotiating our feelings, ideas and values’. In this spirit we called it a ‘A Space to Think and Connect’. It needed to be process driven and relationally focused so that teams could connect through meaningful, non-blaming conversations, that allowed for mixed views, perspective taking, making links (self-others, past-present), naming patterns and highlighting shared experiences for the re-working of stories together. It meant keeping the reflective thinking space going, not getting pulled into problem solving or trying to find solutions (although high- lighting what teams needed from each other was important) and ensuring that the conversation did not go round in circles or get stuck on blaming or criticising (self, others, systems). It meant facilitating the group so that vulnerability was allowed, so that there was a place for feelings and emotions to be expressed and held by the group ‘hovering and shimmering’ within and between the difficult places’ (Potter, 2020).
Method
‘A Space to Think and Connect’ involved four, one-hour group sessions, usually held once a week for four weeks, in person or remotely. The block of four group sessions allowed for momentum to gather and for the team to feel safe to be able to speak about and explore together, what they were going through. The initiative was available to any team or group of people working within the public health system in which we worked.
During each group the facilitators’ outlined the parameters of the space including the core purpose. The groups were confidential, and the facilitators would check in with participants afterwards if indicated (i.e. level of distress and support with coping) and participants could contact the facilitators if follow-up with needed.
All facilitators attended a briefing which included the rationale behind the initiative, key purpose of the group spaces and guidelines about how to structure each group session and the overarching process over the four groups sessions. There were guidelines developed for the facilitators on how to facilitate the groups in a relational, process driven way including how to get the conversation going such as:
‘What have peopled noticed (within themselves or others) in relation to the impact of the pandemic at work?’
‘At a time like this it is as important to talk about how we are working together, as much as what we are doing or the tasks of the role – what have peopled noticed has changed in their working relationships?’
‘Whilst it can be incredibly hard to speak about what you are going through, it is possible that your colleagues are thinking and feeling similar things, either way, speaking about this together can help us feel more connected and reduce the sense of isolation – would anyone like to say what’s coming up for them?’
‘What changes have you noticed in yourself and others at work, related to the pandemic?’
Guidelines on how to keep the thinking space going included:
’What are you noticing as we speak about this?’
‘Does anyone else think or feel the same or have a different experience?’
‘Is this something that it shared by others?’ ‘Is this a familiar pattern or theme?’
‘What’s it like to hear others say these things or to feel these things?’
Ten-minutes before the end each meeting was brought to a close and the facilitators would provide a summary of what was covered, highlighting themes and relational patterns, and reflecting on the process within the group e.g.
‘How did we work together today in this space?’ ‘Was it easy or hard to speak?’
‘How were moments of difficulty managed? Is there anything left to say today or that we need to continue to focus on or re-visit?’
‘What can be taken away from today in terms of helpful ways of coping or things that have come up today?’
During the second, third and fourth group meetings, the facilitators would review the overall purpose of the initiative, the parameters, and expectations of the 1-hour session and summarise the key themes, patterns and discoveries from the previous group. At the fourth and final group space, time was spent reviewing the whole process and pulling together what was discovered, what people were taking away and what they were going to focus on as a team moving forward.
A small group of senior multi-disciplinary mental health clinicians from within the service were involved with this initiative and used their core clinical skills to facilitate the groups. The Cognitive Analytic Therapy trained facilitators were able to also use mapping to support the process, including mapping the patterns of interaction (reciprocal roles and procedures), feeling states and ways of coping. At the discretion of the facilitators, there were times when letters were written to the group, summarising what was discovered together, and the process experienced, to support the development of a cohesive, shared narrative that included learnings and a sense of things that can be taken from this experience (see later in the paper).
Each block of four groups had two facilitators, whereby the primary facilitator took a lead role in introducing the group, defining the parameters including confidentiality, facilitating the discussion and ending. The secondary facilitator focused on: documenting who was attending for the purposes of evaluation and in case follow-up was needed in times of distress being exhibited; helping the primary facilitator to not get pulled into problem solving or stuck on finding solutions. Additionally: they monitored the (often virtual) space to ensure that anyone who wanted to speak had the opportunity; watched to see if any participant was expressing an emotion that needed to be attended to; monitored the online chat; ensured that the group ran on time and sent all participants an e-mail link to complete the evaluation measure post each session. Supervision was provided from a CAT practitioner to support the facilitators, retain the focus of the initiative, and monitor feedback. Holding in mind that this initiative was developed quickly, in response to the rapid and unpredictable pace of the pandemic, we used feedback from both participants and facilitators to make tweaks which aimed to improve the initiative on an ongoing basis.
Findings
‘A Space to Think and Connect’ was initially offered to teams working within Peninsula Health’s Mental Health Program, Victoria, Australia. Through word of mouth, we were asked to offer the spaces to teams working in the general hospital, including those working on the COVID- 19 wards and Suspected COVID-19 wards. During 2020 and 2021, forty- six groups sessions took place, with 361 participants attending, from 16 different teams and including a range of disciplines (both clinical and non-clinical). The RAM-bv was sent to all participants and completed on 108 occasions (or 30% of the time), and we are unsure as to the reasons for this low completion rate, hypothesising that many attendees were working on the wards and did not have much time. The results are summarised in Table 1.
Table 1. Summary of response to the RAM-bv for 108 occasions (30% of the time).
Table 1 shows that for the most part, the spaces provided time for reflection (thinking and feeling) on the impact of the pandemic on work and working relationships. The findings indicate that the group spaces helped teams to speak together and voice their opinions and feelings, providing room for mixed feelings and uncertainty, making links and identifying shared patterns (interactional, feelings, ways of coping, learnings) and were able to tread carefully over difficult and sensitive issues. There was, mostly, respect for differences of background and identity.
In relation to the ‘neither agree nor disagree’ responses, there were certainly challenges experienced in navigating topics such as the divisive nature of the pandemic (including making sense of some of the broader community perspectives on the pandemic such as feelings of alienation), exploring changes to work practice, not being solution focused on problem-solving, staying with the push and pull of powerful feelings (including fear) and tolerating uncertainty.
We had twenty responses to the additional question that was added towards the end of 2021. In relation to these responses, the authors identified a number of themes (summarised in Table 2).
Table 2: Responses to ‘Name one thing you found valuable’ about ‘A Space to Think and Connect’ summarised by themes.
A number of patterns and themes emerged in the group spaces. Throughout the pandemic, and most notably during the early phase, the unpredictability and uncertainty of the situation was related to ‘intense’ feelings of fear. The unfolding situation felt ‘unsafe’ with fears about serious illness and contagion (self and others). The unpredictability and uncertainty was connected to’‘not knowing’ what was going to happen with the virus and its impact at work and it was this that was spoken about in relation to ‘overwhelming’ feelings and being ‘in survival mode.’ Individuals, teams and the system were in survival mode as a way of coping, yet this impacted reflective and relational capacity as’people (and the system) reverted to more narrow ways of relating, which manifest in patterns of interaction such as controlling-to-controlled (hypothesised to try and gain certainty and reduce anxiety, only to feel more over- whelmed with this was not achieved or conflict between people triggered) and blaming and criticising-to-not good enough (relating to the unrelenting tasks and striving to ‘keep up and keep going’ so as not to let anyone down).
The shared pattern of disconnecting-to-disconnected was spoken about in relation to the multiple changes in work practice that were both understandable and necessary, but disconnecting nonetheless: PPE, redeployment, furlough, losing ‘the team room,’ physical distancing (less opportunity ‘for banter’ or ‘de-briefing’) and remote working. There was a loss of familiar professional narratives and safe spaces to retreat to as a team and ‘relentless battling on’ became a familiar narrative. The constant changes and demands on healthcare meant that healthcare workers were ‘drowning in work’ yet had to keep going (‘be heroic’) to provide an ‘essential service’ and to avoid feeling guilty by ‘letting down’ colleagues. The relentlessness of the situation meant the hoped for place of certainty and ‘heroic’ care was unsustainable, with exhaustion and fatigue and the counter position of ‘letting down’ experienced.
The divisive nature of the pandemic was often spoken about ‘COVID- 19 divides people, at home, at work, in the community.’ The divisions related to vaccination mandates, severity of the virus, treatment options, workplace changes, and lockdowns. There was division felt between healthcare workers and the community, with the former speaking about how latter group had ‘no idea’ what it was like to be working in healthcare at the time. Examples of this including the daily reporting of COVID-19 cases having a different meaning for healthcare workers with them knowing ‘what this really meant’ in terms of hospitalisation and possible deaths, whilst for others in the local community it meant mostly restrictions and economic impacts. Nursing staff in particular spoke about the challenges in nursing people with COVID-19 including how patients’ condition can ‘quickly change’ and that they were having to deal with ‘more deaths than usual.’ There was a split noticed between those that saw healthcare workers as ‘heroic’ versus those that were frightened of them (contagion) and/or angry as they were seen as aligning with vaccination mandates.
Conversations that highlighted shared patterns and themes, allowed for collective meaning-making such as understanding different ways of coping with feelings of fear and uncertainty and how this influences how we interact with ourselves and each other and how we can get stuck in one position or yo-yo between one place and another (see controlling chaos map Figure 2).
Figure 2
The map in Figure 2 was primarily developed by one team, but shared, reflected up, and added to, by others usually when the same, or similar themes, were being discussed. This allowed us to share common themes and experiences, deepening the collective and shared understanding and narrative, across teams. It was also used by the facilitators to self- reflect on the challenges experienced by many teams, as well as that of the facilitators in terms of holding some difficult feelings and not getting hijacked by the uncertainty and overwhelm. For example, CAT procedures such as: it is ‘safer’ to be blaming and angry, than it is to feel criticised and not good enough. Or: feeling unsafe and anxious, we seek certainty and can become controlling or feel controlled ’which can lead to becoming blaming and criticising or feeling exhausted but fearing letting colleagues down can lead to ‘relentlessly battle on’ and to be seen as ‘heroic’, only to feel more pressure, exhaustion and burnout over time. Mapping these out through conversations and sometimes on paper as in Figure 2 helped sustain a level of relational awareness and reflective capacity.
We learnt from participants to highlight ‘learnings and ways of coping’ at the end of each group. In line with CAT language, these were sometimes called ‘exits,’ with other names used including take-away’s and learnings. Things spoken about included: making time to savour moments for incidental conversations and connection; not underestimating the importance of focusing on what I need (or my colleagues need) in any moment; look out for ‘moments of joy’ (the sunrise on the way to work; or the sounds of the birds); go back to basics (the garden; craft; walking with the dog); zoom parties; talk to each other (make time outside of work if needed); have a balance between information about COVID-19 – turn the news off if needed and tell your family/loved ones that you don’t want to talk about it; give each other permission to take time off, even if it’s only a ‘1 /2 day’. If feeling totally overwhelmed, recognise that fear is understandable ‘it’s okay to feel this way’; sit with not knowing (as opposed to trying to find the answers); build relationships with those that you wouldn’t usually get to know; remember that if a colleague is being different to how they usually are, they are probably not coping and ask ‘are you okay?’ as opposed to getting into arguments; and remember we are more likely to understand what is being experienced.
In specific relation to the divisive theme, some teams spoke about there being ‘no winners’ or ‘easy answers’ and there needing to be ‘less divisiveness and more shades of grey’. Other qualitative feedback included the group spaces having a role in ‘facilitating common ground’ through the hearing of each other’s experiences and comfort in knowing that others felt the same, that they supported connection at a time of ‘disconnect’ and allowed naming and ‘sitting with’ vulnerability and confusion.
The group meetings were not always ‘easy’ spaces with powerful emotions often expressed and strong opinions voiced. Challenges in facilitating the spaces included not letting the conversation get lost in blaming or criticising (self, others or system). It included not letting the discussion get hijacked by systems issues, in providing solutions, or go round in circles talking at each other without much relational awareness. It meant recognising the dance of feeling overwhelmed and acknowledging our own sense of helplessness in not being able to do more given the understandable (and realistic) anxieties faced by many teams we spent time with.
On a few occasions the facilitators wrote a letter to the group summarising the process and reflecting on the journey together. Whilst this was not part of the original protocol of the initiative, it organically developed through working with groups who were developing a narrative that was helping them find meaning. Some snippets from letters written to groups are shown on the left cloud in Figure 3 and snippets from a letter written back to the facilitators are shown on the right cloud in Figure 3.
References
Billings, J., Greene, T., Kember, T., Grey, N., El-Leithy, S., Lee, D., Kennerley, H., Albert, I., Robertson, M., Brewin, C., & Bloomfield, M. 2020. Supporting Hospital Staff During Covid-219: Early Interventions. Occupational Medicine.
https://doi.org/10.1093/occmed/kqaa098
Chana, N., Kennedy, P, and Chessell, ZJ. 2015. Nursing staff 's emotional well-being and caring behaviours. Journal of Clinical Nursing. 24 (19-20).
https://doi.org/10.1111/jocn.12891
Greene, T., Harju-Seppanen, Adeniji., Steel, C., Grey, N., Brewin, C., Bloomfield., & Billings, J. 2021. Predictors and rates of PTSD, depression and anxiety in UK frontline health and social careworkers during Covid-19. European Journal of Psychotraumatology. 12(1).
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Greenberg, N., Docherty, M., Gnanapragasam, S., and Wessely, S. 2020. Managing mental health challenges faced by healthcare workers during the covid-19 pandemic. BMJ. 368: m1211.
https://doi.org/10.1136/bmj.m1211
Howgego, IM., Owen, C., Meldrum, L., Yellowlees, P. Dark, F., and Parslow, R. 2005. An exploratory study examining rates of trauma and PTSD and its effect on client outcomes in community mental health. BMC Psychiatry. 5:21. P1-17.
https://doi.org/10.1186/1471-244X-5-21
Potter & Bonfield, 2020. Relational Awareness Measure (RAM): Process of Development.https://www.mapandtalk.com/_files/ugd/ 524d79_83b895c156fb41e0a7aa10c972d006d2.pdf.
Potter, 2020. Therapy with a Map. A Cognitive Analytic Approach to Helping Relationships. Shoreham-on-Sea Pavilion Publishing.
Potter, 2022. Talking with a Map Shoreham-on-Sea Pavilion Publishing.
Richins, Gauntlett, Tehrani, Hesketh, Weston, Carter & Amlôt. 2019. Scoping Review: Early Post-Trauma Interventions in Organisations; Final Report; Public Health England.
https://doi.org/10.3389/fpsyg.2020.01176
The Kings Fund. https://www.kingsfund.org.uk/publications/creating- space-conversations-covid-19
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Discussion
‘A Space to Think and Connect’ was developed in response to the rapidly unfolding COVID-19 pandemic. It was an attempt at providing a relational response to a pandemic that was divisive and disconnecting and impacting on relationships through limiting relational awareness and reflective capacity. Throughout this process we were remined about the therapeutic role of letter writing, or providing written narratives (paragraphs), that captured key moments shared by teams and were thus used to support meaning making. We also learnt to routinely use mapping as a key component of the discussions, helping to anchor them, capture key moments and ensure they were conversationally meaningful. For the CAT practitioners, this meant identifying one or two key reciprocal roles and procedures, whilst for non-CAT practitioners it meant ‘words on paper’ that captured enough of the themes and flavour of the discussion. More use of CAT templates could be considered for future iterations, alongside using pre and post measures to better capture how these kinds of reflective spaces are experienced.
At the time this initiative was developed, there were only a few CAT practitioners in the organisation, thus it was not possible to use the CAT model in its traditional form. However, CAT thinking underpinned this initiative and CAT tools played a role in supporting the discussion ‘spaces’ to be run a certain way and within a relational framework. All the facilitators were senior clinicians with training and supervision provided by a CAT practitioner, which was enough for the initiative to meet its core purpose. Given the wide-ranging impact of the pandemic, and the increasing number of traumatic events in the world more broadly, it is important to consider the upscaling of therapeutic interventions so that they have greater reach across the organisation.
Acknowledgements
We would like to acknowledge all of the teams that took part in ‘A Space to Think and Connect,’ many of whom took a risk and gave each other permission to be vulnerable. We would also like to acknowledge the other facilitators and persons who supported this initiative (in alphabetical order): Meghan Bartle, Blake Blain, Rohan De Mel; Bronwyn Lawman; Ruth Lonie; Ann Fuller; Ellie Newman; Fiona Reed; Kerryn Rubin; Alexandra Savage; Tim Twining; and Stuart Wall.
Conclusion
We imagine many readers will be familiar with the accounts arising in this brief evaluative study. This initiative was implemented in the early phase of the pandemic, in response to the intense fear that was experienced by many working in public health and the multi-layered impact the pandemic was having at work including on relationships. Through providing protected time for teams to come together to stop, think and feel with others working within the same system, we hope it had a supportive and holding function. The evidence from our evaluation is encouraging. The ‘divisive’ theme spoken about by many teams reinforces the need for a focus on relationships to navigate, and counteract, tensions and fragmentation. Indeed, the group format and process-driven facilitation meant that there was a focus on how people were working together and that peer group processes enabled experiences and feelings to be voiced and heard.