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Relational patterns amongst staff in an NHS Community Team

Staunton, G. Lloyd, J. Potter, S., 2015. Relational patterns amongst staff in an NHS Community Team. Reformulation, Summer, pp.38-44.

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Introduction
Work can be a signifi cant part of our identity and a place where we experience powerful feelings. This is particularly true
in helping roles, which we enter often seeking an idealised helping role such as caring in relation to gratefully cared-for (Lloyd, 2011). People may feel loved and valued when things are going well, but they may feel minimized, useless or worthless when they run into difficulties (Walsh, 1996).

The coping strategies people employ as a result of problems and diffi culties at work can be signifi cant for their emotional well-being (Aitken and Schloss, 1994). As a result there have been attempts to help staff reflect using a psychological model. For example, recent research has found that the application of Cognitive Behavioural Therapy (CBT) to health-care settings can
be benefi cial (e.g. Stimpson et al. 2012). However, there may also be scope for more relational and systemic approaches. Walsh (1996) for example, used a Cognitive Analytic Therapy (CAT) model to map out the psychology of a dysfunctional work environment in a hospital, so that it could be dealt with successfully. The current study aimed to offer a CAT perspective for the dynamics of atypical NHS community team; in this case, a learning disability team.

What are the main reciprocal roles and procedures found amongst NHS staff?

One might anticipate that striving for the ideal caring role could be frustrated by barriers such as complex systems and a lack of resources. With this in mind, the political context of the NHS is likely to be of importance. In a reformulation letter, Jones and Childs (2007) discuss the reforms from a CAT perspective. Through clinical judgment, they identified reciprocal roles such as controlling – controlled, threatening – powerless and dismissing – ignored. The procedures described involved feeling it was pointless and risky to try to have a voice in the workings of politics. There was also a significant striving procedure; as demands are put upon staff they strive to meet them but end up overwhelmed and exhausted.

One may also expect some degree of parallel processing between staff and clients. Psaila and Crowley (2006) found special/ perfect – learning disabled, abusing – abused, damaging – damaged, rejecting – rejected and abandoning – abandoned were the most common reciprocal roles for people with learning disabilities in the community.

In the current study, a reflective tool called the Helper’s Dance checklist (Potter, 2013) was used to address the question. The checklist has similarities in function to the Psychotherapy File (Ryle & Kerr, 2002), except that it is specific for people in a helper’s role. It consists of a list of 23 statements expressing different patterns of thought and behaviour or “dances”. People can rate their level of agreement with each statement, which allows them to spot the dances that they often find themselves participating in. In noticing these patterns, people can gain the flexibility to explore alternatives. This study therefore also aims to explore the utility of this tool.  

Method

Design

A qualitative study was used which initially involved the questionnaire, Helper’s Dance’. Several weeks after these were posted back, a one hour semi-structured focus group was held in order to gain further information.

Participants

Participants were 55 staff working with people with learning disabilities in a large mental health trust. The sample included a variety of occupations such as nurses, physiotherapists, psychologists, managers and support workers. The questionnaire was presented at meetings for community teams and at day centres across the county in order to recruit voluntary participants. Seven participants attended the focus group.

Materials

The questionnaire included an introduction, a consent form, demographic questions, the Helper’s Dance Checklist (Potter, 2013) and a debriefing. Each item on the Helper’s Dance Checklist had a 5 point Likert scale for which answers were scored as followed: Always – 5, Often – 4, Sometimes – 3, Rarely – 2, Never - 1. The instructions also asked participants to pick three items in the checklist that stood out for them and explain why they found them important. There was also a space for general comments and reflections to be made about the task.

Procedure

Participants were approached with the questionnaire and asked to complete it within a month and post it back anonymously (participants labelled questionnaires with a unique code). They were then invited to join the focus group, where the initial findings from the questionnaire were fed back to participants to guide discussion. The transcripts and written data was explored with reciprocal role procedure analysis (Ryle and Kerr, 2002), with each piece of data examined for reciprocal roles and procedures by two researchers.

Self-Reflection of the Researchers

The written comments from the Helper’s Dance Checklist did not always provide a clear reciprocal role or procedure if they were defensive or vague. In such cases the comment was skipped. As there was no direct collaborative effort with the participant to find the meaning of each comment, the interpretation was vulnerable to bias, as is often the case in qualitative research. To minimise this issue, the data was repeatedly revisited to check assumptions and ideas. For triangulation, two of the researchers analysed the data separately and then compared results to find common ground.

Researchers

Overall

Eighteen reciprocal roles were extracted from the data in total. Though many more were found, similar roles or variations on a
theme were collapsed into more allencompassing roles for simplicity. 
 

The Core Reciprocal Roles

Six reciprocal roles were identifi ed which reoccurred thematically throughout the data obtained by the Helper’s Dance checklist and focus group. Examples of quotes which illustrate each reciprocal role are included in Table 1.

Overwhelming and Overwhelmed	“I can feel very responsible and will personally take on too much. I like to feel I’m needed but in turn this can be overwhelming. Sometimes I feel obliged to help”
Controlling to Controlled	“I often want to try something different with a client or to be more creative but can be prevented or discouraged from doing so by my supervisor or the systems around me.”
Rescuing to Rescued	“It can be a feeling of winning in a fi ght when you get through to people…the feeling of making a breakthrough and affecting the attitudes of a whole institution and the lives within it.”
Criticising to Criticised	“...emotionally it is easy to berate myself for a lack of commitment as if any failure is evidence of underlying selfi shness”
Judging to Judged	“I have experienced the result of showing my feelings…and some had seen that as weakness or attention seeking and the response was uneasy for me to understand.”
Protecting to Protected	“I can feel that I am holding back and waiting to see what the rest of the group are going to say or assess how they are feeling before saying my view.”

The Frequently Danced ‘Dances’

The corresponding items for “If at first I don’t succeed”, “Lack of Resources frustrates me”, “Never good enough” and “Jump in” elicited particularly high responses for “often” and “always”. Figure 2 shows how participants responded to items on the Helper’s Dance checklist.

A Sequence od Dances - "Striving to Meet Demands"

Analysis of the data found overlap in the highly scored dances suggesting that in many cases, they may be part of a larger procedure. Therefore, an attempt has been made to map out a procedure which is inclusive of the ideas participants described from each of these dances. For this article, the procedure is labelled “Striving to Meet Demands” in reference to the procedure described in Jones and Child’s (2007) article.

Note that the core reciprocal role “protecting – protected” is missing as this was judged to tap into other dances. More detailed and individual procedures could only be tentatively speculated on without further information from the participants. Figure 3. Illustrates this procedure visually. The procedure can be explained as follows:

Many participants described how their workload has been steadily increasing and becoming less relevant as they are controlled from orders above. They then attempt to take the rescuing role and feel highly responsible and obliged to meet such demands for the benefit of the people they help:

“Expectations of what can be delivered are increasing – this results in a tipping point when I know I can’t deliver – my capacity is finite”

“I keep falling into the trap of overworking…this leads to me taking on too much work, working outside of hours, running over
time with sessions. I think this is because I am a people pleaser.”

However, this is not always possible due to various barriers, such as lack of resources, which can lead to becoming overwhelmed, frustrated and helpless:

“Frustrated (is my) most common feeling…I’m not good when I feel things are out of my control and there is nothing I can do.”

“I can feel very frustrated by funding issues and the impact on people’s lives. Lack of technical resources leave me
frustrated and stressed.”

They then feel a failure and are self-critical and judged, and this prompts them to try even harder next time, jumping in at the
deep end and never giving up.

“I often feel my help will be inadequate and the client would be better off seeing someone more skilled/qualifi ed/experienced.
I’ll expect the client and the other professionals involved to feel disappointed in my help.”

“I continue to doubt myself and push myself to be better”

“I am heroically tenacious – not always a good thing”

Discussion

This study explored the most common reciprocal roles found in those in helping roles within the NHS. Six common reciprocal roles were identified:

Overwhelming – Overwhelmed
Controlling – Controlled
Rescuing – Rescued
Criticising – Criticised
Judging – Judged
Protecting – Protected

In addition, this study aimed to fi nd the helping dances most resonant with NHS staff. Four in particular were commonly  identifi ed as relevant by participants:

If at fi rst I don’t succeed: I will try and try again to help until I am defeated or successful.

Lack of resources frustrates me: I know what needs doing and how to help but often the money, the treatment or support
is not available and I feel frustrated, angry or helpless.

Never good enough: I have high expectations of myself, which makes me think my help won’t be good enough, others will be
disappointed in me and I will cope by trying even harder.

Jump in: I am quick to get involved at the deep end, giving my all.

From the dances that scored highly, any of the related comments appeared to overlap and so the “Striving to Meet Demands” trap has been suggested as a common combination of dances. Most commonly the procedure leads to helpers feeling overwhelmed, and participants often described feeling frustrated and helpless. However, for some the feeling of being overwhelmed is taken as a personal failure and leads to self-criticism and feelings of judgement from others. These ideas are significant in that several participants mentioned burning out. The trap is also likely lead to low morale and many comments are suggestive of unhappiness.

The protecting – protected reciprocal role seemed to have separate but numerous and diverse functions and so it was judged to be a core reciprocal role. It was highly reoccurring in both the Helper’s Dance data and the focus group. For some this was a ‘selfself’ reciprocal role which kept their true feelings safe but unheard as expression was seen as a risk. This therefore ties in with another highly scoring dance; “If genuine then vulnerable”. To others, this was an exit to a stress trap at work by either being assertive about responsibilities or by switching off to avoid taking stress home and being a burden to their family. Participants also mentioned being protected and contained by their superiors and taking the protecting role with clients.

There were many positive aspects to the data. Participants often put forward their own exits to traps. Exits for the “Striving to meet demands” trap included choosing battles wisely, accepting one’s own limits, seeking support from others, redefining how success and failure is viewed and building and maintaining a healthy home and work life balance. In addition, the feedback for the Helper’s Dance task was overwhelmingly positive. Out of 36 comments, 25 felt they benefitted from the task, 8 were neutral comments (usually mentioning that they found the task difficult but interesting) and 3 were negative (e.g. “repetitive task”, “the questions were leading”).

In terms of parallel processing there is mixed evidence. 4 of the 6 core reciprocal roles of the current study were found by Psaila and Crowley (2006) and 9 out of the current 18 reciprocal roles matched in total. Protectingprotected and judging-judged did not match, although unhearingunheard may account for some of protecting-protected. It is noteworthy that staff in community teams often work indirectly with clients in learning disability settings through systems, which may account for some of the differences. However, it is also possible that some of the current reciprocal roles are too specific or sophisticated. Generally those with learning disabilities have less diverse reciprocal roles than the general population (Psaila and Crowley, 2006).

The findings supports the commentary of Jones and Childs (2007) that the striving to meet demands trap is a common procedure for NHS staff with controlling – controlled being a key reciprocal role. This is likely to be fuelled by the continuous changes in the NHS.

Implications

The Helper’s Dance checklist is likely to be a useful reflective tool for those in helping roles and a valuable aid for unlocking rich information. The findings from it provide a framework from which to guide interventions or training in staff teams using a CAT model. The wealth of exits provided suggested it would be a useful experience or staff teams to reflect together using the Helper’s Dance to share their feelings and ways of coping and to help build beneficial relationships in a staff team.

Limitations

As this audit aimed to find common reciprocal roles, it required a reasonably sized sample of participants. As a result, due to limited time, a questionnaire had to be used, which prevented an interactive exploration of the ideas participants presented. This resulted in using the ‘Helper’s Dance’ in a way in which it was not originally intended, i.e. as a tool to fill out and then discuss together as a group to share ideas. The focus group was held to help alleviate this limitation.

The researchers note that while most of the comments were reflective, some were defensive or distanced and so they may have found the task exposing. This may have been particularly difficult for those who knew the researchers well, though confidentiality was strongly assured and enforced.

As multiple teams were used, the sample is easy to generalise to other community teams for people with learning disabilities. However, it may run into difficulties generalising to other client groups and primary care, and so further research is required to see if the same themes are consistent throughout the NHS and other care organisations. The findings are somewhat NHS specific and so are not generalisable to those helping outside of the service (e.g. family carers).

Conclusions

This study used the Helper’s Dance checklist to explore reciprocal roles and procedures in an NHS community team. The results indicate that the ‘Helper’s Dance’ can be a valuable tool for professionals looking to explore and work with morale and relationships amongst staff teams. As staff feel their greatest challenge comes from systems and external influences out of their control, CAT can be a useful tool to map out these dynamics as well as helping people reflect on the dances they take part in as a result.  

Graham Staunton is an Assistant Psychologist working in the Community Team for Older People at Farnham Road Hospital, Guildford. At the time of undertaking this research, he was working as an Assistant Psychologist in the Community Team for People with Learning Disabilities in the Aldershot Centre for Health, Aldershot.

References

Aitken, C.J., & Schloss, J.A. (1994). Occupation Stress and Burnout amongst Staff Working with People with an Intellectual Disability. Behavioural Interventions, 9 (4), 225-234. Jones A. and Childs D. (2007). Reformulating the NHS reforms. Reformulation. Summer, pp.7-10. Lloyd J. (2011). Consulting with Staff Teams. Clinical Psychology & People with Learning Disabilities, 9, 1. Potter, S. (2013. The Helper's Dance List. In: Lloyd, J. and Clayton, P. Cognitive Analytic Therapy for People with Intellectual Disabilities and their Carers. London: Jessica Kingsley Publishers, pp.89-121. Psaila, C.L. and Crowley, V., (2006). Cognitive Analytic Therapy in People with Learning Disabiltiies: an Investigation into the common Reciprocal Roles found within this Client Group. Reformulation, Winter, pp.5-11. Ryle, A. and Kerr, I.B. (2002). Introducing Cognitive Analytic Therapy. Sussex: John Wiley & Sons Ltd, pp. 232-240. Stimpson A., Kroese B.S., MacMahon, P., Rose N., Townson, J., Felce, D., Hood, K., Jahoda, A., Rose, J., & Willner, P. (2012). The experiences of staff taking on the role of lay therapist in a group-based cognitive behavioural therapy anger management intervention for people with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities, 26, 1, pp.63-70. Walsh (1996). Adapting Cognitive Analytic Therapy to make sense of Psychologically Harmful Work Environments. British Journal of Medical Psychology, 69, pp.3-20.

Full Reference

Staunton, G. Lloyd, J. Potter, S., 2015. Relational patterns amongst staff in an NHS Community Team. Reformulation, Summer, pp.38-44.

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