e31 Resilience
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Multi-professionalism, chaos & overload
[00:00:06] Munir Adam: Welcome to Primary Care UK. I'm Munir Adam, and today, we are joined by Dr. Rachel Morris, a GP turned executive coach, who will be teaching us about surviving and thriving as general practice becomes more and more multi professional. And I say we, because I'm also joined by our newest recruit to the Primary Care team, who is...
[00:00:26] Claire: Hi, I'm I'm Claire Green. I'm a paramedic by background and I joined primary Care back in 2017. So, um, I'm here to kind of represent views of paramedics and share experiences from what I've seen so far, really.
[00:00:39] Munir Adam: Thank you. So, yeah, a whole variety of new roles enter Primary Care. The GPs and nurses who are so busy, their challenges are finally over. And everybody lives happily ever after. Well, if you honestly believe that is the case, you should stop now. Because ignorance is a bliss.
[00:00:56] Claire: But if you don't believe that and actually, think that you could do stuff to feel better and survive and thrive regardless of where you work, then let's find out.
[00:01:07] Munir Adam: So, we're in Season 2, which is produced in collaboration with Integrated Care Support Services. And in Season 2, we have true representation from a multi professional team, which you can find out about by following our links. Now, I started this podcast because of the acute awareness of some of the challenges that having multi professionalism brings.
[00:01:36] I mean, yes, it's great and there's a lot of advantages and important reasons why primary care is becoming multi professional, but what about the confusion? What's my role? And some professions, they feel threatened. Then there's the uncertainty about how to do these roles well. I mean, there's so much variability, right, from one practice to another.
[00:01:54] To be honest, it's all very experimental. And there are people trying to speak to the whole multi professional audience, but often it's done really badly. And even when people use headings like primary care, they're actually only speaking to one profession. So we don't want to divide, you know, we want to try and unite the workforce.
[00:02:11] Just to be clear this episode is not about the politics of it. It's not about system change at a big level. It's not about what NHS England or anybody else should be doing, but actually how do you survive on a personal level? How do you cope with all of this? I don't know the answer to that, but I have Rachel with me. So Rachel, if you could please introduce yourself and what you think some of the challenges are, perhaps, first of all.
[00:02:33] Rachel: Thank you so much for having me. So I'm Rachel, I'm the host of the You Are Not A Frog podcast, and I also founded an organization which is dedicated to helping people in high stress jobs, high pressure jobs, beat stress and work happier. So consequently we work with a lot of healthcare professionals.
[00:02:51] Just a bit about my background. I, um, taught for many years at Cambridge University. I was assistant director of GP studies, and I also set up and led their doctor as a professional curriculum. I also trained as an executive and team coach.
[00:03:05] Healthcare professionals aren't brilliant at their own resilience. You know, my aim now is to really help people thrive, not just survive in their really very difficult day jobs. And we've definitely seen that get worse over the last few years. When I first started teaching around resilience, well being and stuff, I used the stress curve, which is the very simple Yerkes Dodson curve, which shows how we perform under pressure.
[00:03:28] And I ask people to rate where most of their colleagues were. Did they feel that they were at peak performance or did they feel they were, you know, starting to slip down the performance curve or getting even further towards burnout? And I've seen a definite shift. Whenever I talk to audiences, before COVID people would say, well, they're either at peak performance or just starting to slip off the curve.
[00:03:47] And now we're saying most people are, they say they're definitely slipping off the curve or even further, further down towards burnout. And so I think the first challenge is really the fact that most of the workforce, I think, are starting to slip off that curve. Whereas before, you'd have some people that were burning out, and not everybody was. Many people are almost one crisis away from not coping, and so the NHS as a whole, I think, is very stressed. Which then makes it harder for us to care for ourselves and care for each other. And then sets off this vicious cycle of people going off sick with stress, leaving less people to do the day job, meaning that people have got more work, which means that they're overloaded, so it becomes this sort of vicious cycle.
[00:04:32] So I don't know if that's your experience at the moment.
[00:04:35] Munir Adam: Certainly as a GP all I hear doctors say is complain about not having enough resources, time and the stress that goes along with it. But Claire, does any of that resonate with you as a paramedic?
[00:04:46] Claire: Yeah, absolutely. I mean, like Rachel alluded to, you know, over since COVID, I've seen a big change in the kind of staff distribution at work. It was very GP heavy initially, and we've seen a massive drop off, people taking early retirement, burnout, and just lack of job satisfaction. There's less time, there's less resources.
[00:05:06] They're not feeling that they're able to actually invest what they need to in these patients. There's a lack of continuity because people aren't able to kind of see the same GP every time. And it's, it's, you know, it's a double edged sword really because you've got the, you know, implementation of this MDT structure within primary care, but essentially that then leads to patients seeing different people every time.
[00:05:28] I don't think enough importance is put towards sort of self care and having the time to do that is always really tricky. It's always at the bottom of the list, I certainly find that with myself, you know, it certainly comes last.
[00:05:40] Rachel: So Claire, I think you've hit the nail on the head there because what I've observed is that, you know, people have seen that people are under immense amount of stress and people have looked into the NHS and gone, right, how do we help? How do we help? I know, let's tell them to do more self care. Let's really focus on wellbeing.
[00:05:55] And as you've just said, that's great. And I would love to have more time for self care, right? But actually, if there's not enough of you to do the job and you don't want to leave patients not being seen, and you want to keep everybody safe, so you end up giving that time when you would spend looking after yourself and you would spend going for a run or, you know, on your own wellbeing, you end up working. And so self care goes to the bottom of the pile. And then people just telling you about the importance of self care, it's not helpful and at its worst can feel very annoying and can feel quite like resilience victim blaming.
Challenges, mindset and how to think differently
[00:06:27] Munir Adam: Okay, so we can all agree that that is a big problem. What can we do about this?
[00:06:33] Rachel: It's tricky, isn't it? And the first thing I would say is recognizing where we all sit in a very complicated, difficult system, because without a doubt, the system needs to change. And there are people working incredibly hard to change the very, very complex system which we work in. But what I've noticed a lot of people do is they sit there going, well, until the system changes, nothing's going to be better until that happens or till we get more resources or till we get this.
[00:06:58] And if we wait to be okay until the system changes, we're never going to be okay. So I think it's all about, well, there's three, there's three things that we need to do. The first one is realize that we always have a choice and it's yes, a system needs to change, but we are choosing to carry on working within the system.
[00:07:18] Some people aren't, some people are choosing to leave the system, but while we are choosing to carry on working, there are things that we can do to help ourselves. There are things that we can put in place. But some of these choices that we need to make are quite difficult choices. It's not that we don't have the choice is that they are too difficult to make.
[00:07:37] So the first thing we get people to do is we say to people, work out what choices you have, because there's absolutely no point in railing and getting very cross and upset and putting all your effort into changing something you have no control over. So, for example, we have pretty much no control over patient demand or for, for example, what the media publishes.
[00:07:56] It's a waste of energy worrying about that, but what we don't do is pay enough attention to some of the choices that we do have. Often that is doing things like prioritizing our workload. And of course, if we prioritize things and say, right, we don't have enough people, therefore we are only going to focus on the things that are really important right now. That sounds great, doesn't it? Yeah, we can all get behind prioritizing important stuff. If you do that, if you're saying yes to the important stuff, what's happening? You're saying no to other stuff, which might be important to other people.
[00:08:28] And it's when we then have to say no and deprioritize other stuff. That's when it gets really tricky. You know, most people working in healthcare are really good people. They want to do their best for the patients. They want to be there. They want to help people. And then to have to say no to stuff.
[00:08:45] And can I just be really clear, I'm not talking about saying no if, if someone has a very serious urgent health issue, because of course we go and help them. But this is some of the, the other stuff that comes at us, that it's okay to say no to, it's safe to say no to. But we feel dreadful. We feel guilty. We feel awful. We don't like either the thought that we might be dumping on colleagues or the thought that we might be causing other people some inconvenience.
[00:09:09] So these thoughts and these feelings of guilt stops us from being able to prioritize what's really important, stops us from setting appropriate boundaries so that we can then do the self care. Is that ringing any bells?
[00:09:23] Claire: Every bell.
[00:09:24] Rachel: Every single one!
[00:09:27] Claire: Absolutely.
[00:09:27] Munir Adam: A lot of us, because we're trained in a certain way, we want to almost be like perfectionists, don't we? We just feel it is always our job, it's always our responsibility. I don't think we're very good at saying no.
[00:09:40] Rachel: We're not, and we think we're not very good at saying no because it's, it's about the skills of saying no. And there's definitely some skills that we can learn about how to say no. I've already mentioned guilt. We feel very guilty if we're letting somebody down, but it's a little bit more toxic than that because, well, let me give you an example.
[00:09:56] I broke my ankle last year ice skating, and I had to cancel some, some clients and some training sessions because I couldn't get there. I felt awful. I felt a bit guilty. But, I was interviewing a GP on my podcast and she had been incredibly stressed and had been getting really quite ill and she, she knew she had to go of sick and take some time off to recover.
[00:10:16] However, there was somebody else on sabbatical. There weren't enough doctors at the practice, there weren't enough staff and she knew that if she went off sick, she would, then have to cancel loads of clinics. Somebody else would have to cancel their leave. She wouldn't be able to help patients.
[00:10:30] Her internal values were: I should be perfect. I must always be there to help people. What we do is help people, and if I say no to helping somebody in need then, you know, I'm not just feeling guilty, but I'm starting to bang on my own internal values. I don't just feel guilt, I feel shame. So, this saying no goes right back to our identities because what shame says, it's not, it's not just, I've done something that wasn't great. Shame says, I am not good enough. And that is a horrible feeling. We'll do anything we can to avoid feeling shame.
[00:11:06] Munir Adam: And that is a very uncomfortable feeling to have to live with. And I do think that sometimes people try to cover that or try to deny what they're feeling by just blaming others for the things that are going on around them. And the worry here is that certainly with years and years of doctors and nurses feeling overwhelmed and stressed and so on, that when other professions join, it's very easy to start targeting them.
[00:11:28] If we haven't managed to, uh, understand our own feelings, we might just be not a very nice person to be around when it comes to others as well. And you know, something I was thinking is at least as a doctor, I've always worked in places where there's several other GPs, but sometimes the other professionals coming on board, usually the only one in that practice.
[00:11:50] I don't know if that's true, Claire, whether you would be the only paramedic in your practice or not.
[00:11:55] Claire: Well, to start with, I was, yeah, on my own, when we were a more, sort of, partner led surgery, but when we joined as PCN I got involved with other paramedics and it's gradually been extended to sort of mental health nurses and I can certainly empathize with those that have been in primary care for, you know, its entirety that us coming in and trying to make these changes or upsetting the mix a little bit, I've certainly seen people feeling threatened and there's kind of a lack of role clarity, no one quite knows where their boundaries lie or what everyone can do and, and you know, it took a lot of trust on the GP's part to take me on initially because they had no idea about my skillset, but that's because of a lack of understanding about how much education paramedics now have.
[00:12:43] It isn't simply sort of jump in the ambulance, chuck 'em in the back, drive off. It's very much kind of degree led.
[00:12:49] Munir Adam: So, what can you do? I mean, I'm just thinking back to people who have also said the same thing to me, that they feel that their jobs are being threatened. And on the other hand, you've got professions like paramedics and physician's associates and clinical pharmacists, who are so new to it. And many have said they don't really feel very well supported. So I think there's that sense of isolation as well.
[00:13:08] Yes, it would be great if we could solve all of these problems at a large scale. But how do you manage? So Rachel, you shared a few useful tips already, what else would you say. People who lose their confidence?
[00:13:18] Rachel: They do. And, you know, I've talked about the choice thing about knowing what's in your control and what's not in your control. The second big bit of the picture is knowing about your mindset and what happens to us, you know, when we are under stress, when we are telling ourselves these stories, like you're not good enough, you don't know what you're really doing or, you know, whatever these different stories we're telling ourselves, we go into our fight, flight or freeze zone.
[00:13:38] So that's our sympathetic nervous zones, where we behave badly and we can't be very empathetic. So we're then reacting badly. And so a paramedic might experience a GP as being a bit gruff and rude, whereas actually the GP's just dead scared and it's coming out as rudeness. And then perhaps a new paramedic, rather than asking for the help that they need, might just try and cope by themselves without asking for what they need, because they're too frightened to ask for help.
[00:14:03] For me, it's, it's about firstly recognizing when that's happening and going oh, hang on a sec, we're backed into the corner here. How can we first of all pause, talk to each other and actually say what's going on in my head? I'm always very surprised when GPs don't say to their staff, you know what, I'm really worried here that there might be a mistake and I might have to take, you know, take the blame for it, which is why I'm probably being a bit overprotective. So I'm really sorry. Let me know when I am and you know, so just actually explain what's going on in your head. And likewise, you know, other people need to say, I'm really trying my best here, but I'm not really clear about this. Do you mind going through that one more time? And then we can, then we can do it or saying, actually, you're being a bit, you know, challenging people, but we were so worried about doing that.
[00:14:46] And then if you're thinking about the whole shame thing, and I can't possibly ask, or I can't say no, whatever Brené Brown writes a lot about shame. And she says you know, exposure cuts shame off at the knees.
[00:14:57] So just talking to other people and saying, I'm feeling this, this is a story in my head. What do you think? Which is exactly what Claire was saying with the PCNs, you know, which is why it's so important, I think for these people that are in their additional roles, but isolated within practices to be able to get together in their network and triangulate stuff, compare notes and go, this is what's happening here. This is what happened. What do you think?
[00:15:20] And just get a bit of support and air cover, because then that will increase your confidence next time knowing, well, I'm not alone. What people need to know is I'm not alone. I'm not the only person thinking like this because as soon as they think that they're like, Oh, okay, this is normal.
[00:15:34] Right. Okay. Now I can do something about it. Now I've got a choice. But while we're just in our backs into the corner thinking we're on our own thinking that we're feeling like this because we're not good enough, then nothing can really change. So for me, the biggest thing is recognizing when you're there and starting to talk about it, starting to question some of those stories we're telling ourselves.
[00:15:54] So that we can then actually start to make a bit more rational decisions and approaches to things. And it's a lot easier for someone to say to me, Rachel, that was fine saying no to that. That's completely reasonable. And you would say that to a friend, wouldn't you? But we don't often say that to ourselves.
[00:16:11] We just beat ourselves up. But just being able to speak to our colleagues and getting them to reassure us and say, no, that was okay, it is very, very helpful.
Take home points and next steps
[00:16:19] Munir Adam: Brilliant. Thank you. There's a lot of important points that you've just made. I feel that trying to summarize them would be somewhat reductionist, because different people would take differently from it. And I was also thinking to myself, oh gosh, time is running out. And that's why I think it's great that it's very easy for me to redirect people to your podcast to find out more.
[00:16:38] Whether, you know, you guys listening are thinking, I really do need to explore my own feelings about this, or whether you're just interested to find out more about it, then Rachel, you refer to your podcast when you introduced yourself at the beginning you are not a frog. So that's easy for us to remember and it's very easy to find as well.
[00:16:56] But that said, if you had to give one take home message, what do you think you might, and that's a very difficult one, isn't it?
[00:17:02] Rachel: Well, I'll start with the first principle, we always teach people from the Shapes Toolkit program, which is the sort of training course we run. And that is, what is in your zone of power? Just think, what am I in control of? And what am I not in control of because until you have worked that one out, you're going to waste an awful lot of time and energy on stuff that you don't have control over.
[00:17:22] Once you've done that, then you know what choices you've got and you can start to make some decisions. And if there's a decision that you need to make, but you just feel you can't because you feel so awful about it, then it's a chance to think, ah, this is a mindset thing. What do I need to look at here? What stories am I telling myself?
[00:17:39] Munir Adam: Brilliant. Thank you. Claire, any comments?
[00:17:43] Claire: Just a thank you that I found that really informative and you know, take home messages for me were, really emphasizing that rabbit in the headlight moment and just kind of recognizing it, opening up communication channels, particularly within my kind of role within primary care and the importance of that to sort of enable a better, well supported kind of environment at work, which means that you're happier at work and everyone's just going to do a little bit better.
[00:18:07] So thank you.
[00:18:08] Munir Adam: Brilliant.
[00:18:09] Rachel: Can I just say, if people want to find out more than they can check out the podcast, you are not a frog. com. And what we can also do is give you a little link so people can sign up and get a tool around the zone of power so they can fill that in and do it themselves. And there's a short little video there as well. So.
[00:18:23] Munir Adam: So yeah, uh, we'll include some helpful information in the show notes, but that's it for today. Thank you, Rachel. Thank you, Claire. And thanks guys for listening. And until next time, keep well and keep safe.
Disclaimer
[00:18:33] Munir Adam: primary Care UK was developed by Therapeutic Reflections Limited to inform, educate, support, and unite the primary care workforce. Specifically, it is not for the general public or patients. All information and advice contained therein is time, location, and context dependent and is general advice only.
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