As someone interested in workforce sustainability and support, and the place of coaching in compassionate leadership, and interested in the role supervision can play in staff retention, the question “What does good supervision for NHS clinician coaches1 look like in a pandemic?” has been on my mind.
The question changed multiple times as my inquiry progressed and as I examined what it means to be working as a coach in healthcare during Covid – a landslide of concerns.
As a doctor involved in workforce education in the NHS, the question “What do clinical staff need, in order to flourish in the workplace?” is a frequently considered one.
During this pandemic, the question has become “What do staff need to keep going in their jobs?” More specifically “What are NHS staff bringing to coaching in a pandemic and how can our coaches best support them?”
As I set out to examine this question and consider what form coaching supervision should take, the enormity of concerns that both coachees and coaches are carrying swiftly emerged as a dominant theme.
My role as Coaching Lead includes responsibility for appropriately addressing the CPD and supervision needs of our clinician-coaches. As a practising coach and supervisor in this system, I am also hearing the same burden of concerns from coachees and coaches.
Perhaps not surprisingly given the current pandemic a single coachee can present with a wide ‘circle of concern’2, in addition to their coaching goal. The complicating factor in this system is that the coach may also be holding similar concerns.
Emotive descriptors such as ‘tsunami’ or ‘landslide’ have been used frequently to describe working conditions encountered in healthcare during the pandemic – it did indeed feel like a landslide at times listening to my supervisees.
Many concerns voiced were common to more than one coach. By now the question had evolved into “Given the burden of concerns experienced right now, what form should coaching supervision take?”.
This inquiry is examining what one part of the ‘system’ – clinician-coaches working in healthcare during a pandemic – need to continue their work.
The system that coaches are bearing witness to is of course much broader than individual clinical care, as evidenced by the concerns documented in the appendix.
It is important to note that we are not talking about people incapacitated by their mental health – the coaches and coachees I am referring to feel able to function at work and wish to continue to do so.
This is not an exploration of burnout or the boundary between therapy and coaching, but a pragmatic look at what our colleagues – the carers – are holding and how as supervisors we can support the wider system through providing supervision.
My own experience and the breadth of concerns expressed by others signposted me towards looking at the restorative component of supervision as a practice in its own right.
What did I find?
As I explored further, the theme of self-compassion as an essential ingredient began to emerge.
I reflected on my own experience of self-compassion as a restorative practice and added the question “What do we know about the place of self-compassion in sustaining staff?” to my inquiry: something which I had not contemplated during my training.
Certainly in balancing the needs of others, whether coachees, trainees, patients or their family members, I have found the development of robust boundaries an absolute imperative, in order to manage my ‘rescuer’3.
As Brene Brown teaches “the most compassionate and generous people are the most boundaried”4 and this certainly rings true both personally and working with healthcare professionals suffering burnout.
Professor Michael West’s longitudinal work examining the NHS workforce data provides an essential evidence base as we unpack the links between care of self and care of others.
His work robustly describes:
- The link between positive staff experience and good patient outcomes19 and
- The link between self-compassion and ‘more effective interaction with all those we work with and offer care for’5.
By now, the question had changed from:
“What would good supervision look like in a clinical setting right now”
“What is the place of ‘compassion practices’ in attending to the system (healthcare during a pandemic)?” and “How can we provide supervisory spaces which foster self-compassion and compassion?”.
One of the concerns articulated by many involved in coaching in the NHS is that coaching and supervision become sticking plasters over staff need, in particular where systemic changes to amend demanding working conditions are not occurring.
However, if coaching offers an opportunity for connection to core values and motivation, then it can be a place of self-compassion, and hence safe reflection.
And so I came to compassion practices – practices which are “all about reconnecting people to purpose, humanity, self, and each other, in a way that feels accessible, simple, and straightforward to implement.”6
The practices I chose to explore are the 10-minute pause and #spacesforlistening, both small-group, compassion-based tools amenable to online delivery, and growing in use in the NHS currently.
Both tools have their origins in the Thinking Environment described by Nancy Kline22 and so I revisited her ‘ten components’. Whilst all the components are important in the creation of a Thinking Environment, I am reminded of the particular importance of attention, ease and place in restorative supervision.7
Attention comprises non-interruption and listening with fascination – both ways of communicating compassion to the thinker.
Ease is described as ‘freedom from internal urgency’ – consciously bringing this component invites safe exploration of thoughts and feelings, and the place is creating a supervision space which says ‘you matter’.
Previously, this would have been the physical environment. But working virtually, I have found it to be clear instructions, the respect of and adherence to time boundaries, the equality generated in a round and again the non-interruption and fascination in where someone’s independent thinking will go in their supervision.
Taken together these combinations and the remaining components is a powerful generator of a compassionate environment for independent thinking to occur.
Two points become clear through this line of inquiry:
- That compassion and self-compassion are essential components underpinning any supervision occurring with and for clinicians (indeed perhaps any supervision?), and
- The restorative component assumes a really important place in supervision, given the cognitive and emotional overload coachees and coaches are experiencing in their workplaces right now.
As Kristin Neff, the voice of clarity and evidence on self-compassion explains,
“The beauty of self-compassion is that instead of replacing negative feelings with positive ones, new positive emotions are generated by embracing the negative ones. The positive emotions of care and connectedness are felt alongside our painful feelings”.8
She describes the three components of building self-compassion as tuning in and being aware of our suffering, understanding the common humanity in our situation, and offering kindness towards ourselves.9
In other words, by becoming aware that we are in the midst of a landslide, that others are too and that it is tough, and that we are doing the best we can, we can escape from under the landslide.
The piece that Michael West’s work adds to the picture is that by escaping it ourselves, we are able to assist others in seeing the landslide for what it is and getting out from under it in order to continue to work.
Brigid Proctor’s model describes the restorative, formative and normative functions of supervision;10 she also says,
“practitioners of supervision and healthcare need support and help in seeking virtue and embracing wisdom in a complex and multicultural world. One way they can get this is by being offered regular space to reflect on their moment-to-moment practice.”11
The compassion practices are not claiming to offer supervision in themselves but provide a component of supervision.
Given the burden of concerns coaches are hearing and holding currently this seems a useful route of investigation – to explore the place of compassion practices as tools for bringing ease, mental space, and self-compassion, in doing so paving the way for additional supervisory exploration.
Moreover, commencing supervision without attending to restorative practice would render the session redundant. As Proctor says,
“If supervision is not experienced as restorative, the other tasks will not be well done.”
This makes intuitive sense as well as being born out in the neuroscientific literature: holding numerous concerns without attending to them leaves little space for independent thought, new perspective and appropriate development.12
Proctor’s model acknowledges there are always more than two stakeholders within clinical supervision.
In the offering of restorative supervision, supervisees working in healthcare are empowered to support other staff they meet who in turn can support patients, their families and their wider system. The ripple effect is powerful.13
Proctor references Gerard Egan’s Helper model14, and Heron’s 6 categories of inquiry15, and goes on to describe the value of reflecting, summarising, paraphrasing and exploring further with questions that facilitate deeper understanding.
This contrasts with the compassion models undertaken during this inquiry which use timed rounds, generative attention and non-interruption to facilitate personal reflection and independent thinking.
This underlines the fact that a compassion practice forms part of a supervisory session, not supervision in its entirety.
What was my experience of using compassion practices?
The two models I used were a 10-minute pause and a #spacesforlistening session. I found both tools profound and impactful.
I was invited to join a #spacesforlistening session by reaching out to the creators of the model for the purposes of this inquiry. The session was held via Zoom and had eight participants – the maximum stipulated number.
The practise consists of three timed rounds, with each participant having two minutes to speak per round, managed by a facilitator, with non-interruption agreed as part of the contract.
All participants were on mute apart from the thinker, and speaking was limited to participants’ invited to turn in the round. The questions were:
- “How are you and what is on your mind right now?”,
- “In light of what you have heard in Round 1, what are your reflections and feelings?” and “What is one thing you might take forward and is there an appreciation you would like to share?”
Whilst at first glance these questions appear non-specific in the context of supervision what becomes quickly apparent is that they provide a safe space very rapidly, where participants share very personal and often moving thoughts.
In practice, this means that people deal with what is ‘front of mind’ very swiftly. This quick dive into vulnerability facilitates sharing of unexpected things (more than one participant commented that they were surprised by what they spoke about and hadn’t intended to).
The connection created through shared vulnerability feels very validating even when each other’s content is vastly different. There is enormous potential for rapid connection with people who were strangers a minute ago, and yet the process is ‘stand-alone’. Several participants commented that the lack of introductions or longer-term obligations felt liberating.
My experience of the #spacesforlistening model resonated with my previous use of the Thinking Partnership, specifically that stating and adhering to time boundaries builds and strengthens psychological safety and that two minutes feels incredibly spacious.
Also, that non-interruption is vital in the exploration of the content of one’s thoughts, when previously the content may have been eclipsed by the associated emotional load, or landslide.
It is surprising what emerges from the ‘luxury’ of non-interruption: new insights which may up until that point have been opaque, or unavailable, somewhat out of reach in one’s awareness.
It is profoundly moving to have others bear witness to these and the offering of generative attention (listening with fascination and non-interruption) is both validating and nourishing.
My experience of this process is that even when one is carrying burdensome thoughts, lightness is achieved through having others hear them without further comment.
There is a rich reward of accountability within the group: it may be easier not to think these thoughts than think them but being present and being heard encourages examination of all that one is holding.
That feels necessary for maintenance and self-care. Of course, further work might need to be done in terms of exploring patterns, unhelpful attachments or inference etc. But this deeper work of further exploration is made available through opening the supervision space with a compassion practice and making space for new thinking.
Prioritising listening without offering comment or solution communicates a deep respect for the quality of the thinker’s own reflections and the assumption that the thinker is resourceful, able to attend to their own needs and that they may hold the new perspective they seek.
Another reflection is of how normal it is to receive others’ ideas as ‘good or bad’, ‘right or wrong’ very quickly and without full examination.
Allowing the thoughts of participants to be stated fully and without interruption means we listen to the end of them, where previously we might have ‘reacted’ and switched off. This observation is deeply uncomfortable, yet the awareness is so valuable.
The 10-minute pause presents an alternative, briefer restorative space, again via a script and schedule. The scripted nature of this tool means it can be used by many and without a trained facilitator.
Whilst the presence of a trained facilitator enhances the session, it is not essential, making this a pragmatic offer available to a wider reach of staff. A lack of allocated supervision time or trained staff is a reality for much of the workforce.
The 10-minute pause begins and ends with a round and uses a listening pair in the middle to consider a question and receive and offer appreciation. The opening round is the question “What is something you feel grateful for or that is going well for you?”
The listening pairs occur in breakout rooms or physically in pairs if able to meet in a room together.
This segment offers two minutes each to contemplate uninterrupted the question “What does caring for yourself mean to you?”, and then to offer “One thing I appreciate about you is…” to their partner. The final round is “To be wise, kind and compassionate to myself, I will…”.
The learning from this model reflected much of that from #spaceforlistening and Thinking Partnership work – in short segments of time participants in a group can create authentic and meaningful connections that are moving and profound.
When I ran the 10-minute pause sessions, I found that participants were astounded by their own responses to the self-care question.
These are seasoned healthcare providers, aware of the prevalence of burnout and the need to look after themselves, and yet time and time again commented that this was something that they had lost sight of, perhaps buried under the landslide of the cognitive and emotional load they were carrying.
A frequent comment was “no-one has ever asked me that” (about self-care). Although self-care is replenishment work we need to do for ourselves, asking about it can be a way of offering compassion to colleagues and embedding self-compassion as a cultural norm.
I was also reminded of the power of silence for creating space for independent thought. This allows work to be done and reflections to occur at the pace that an individual requires. It is tempting to feel that as supervisors we add value through reflection, comment, noticing, sharing insights.
Whilst this may be true, there is undoubtedly value to be gained by fostering an environment where the supervisee knows their own thoughts are valued, essential for their own growth and development, and that giving voice to them is an act of self-compassion.
This is advantageous in a group space where there can otherwise be pressure to go at a group-led pace, rather than an individual one.
What did I conclude?
The pandemic has added new pressures to a system already struggling with chronic overload. This combination magnifies risk to patient safety, intention to quit amongst staff, and staff burnout.
Living with the landslide of concerns described in the appendix is deeply damaging. This damage is born by individuals but may be visited by others – colleagues, patients, family members unless attended to.
Clinician coaches are providing welcome space to coachees in the NHS wanting to reach their potential, explore career challenges and bring new awareness to their situation. Both coachee and coach may also be standing in the way of the landslide and require techniques to manage the burden of concerns.
One way of managing concerns is through a group compassion practice. We know that compassion is a core value in health and social care – it resonates strongly with staff as a key purpose for choosing to work in healthcare, and it is also essential for the quality of interaction across teams and with patients.
Yet the healthcare system can be poor at reflecting ‘you matter’ back to its staff. Practices that model staff compassion and embed the statement that staff matter is essential, for good patient care, for staff retention and for quality supervision.
Underpinning the use of these compassion practices is the assumption that taking time to properly examine one’s thoughts is an act of self-compassion.
Without this gift to oneself, it is impossible to be present for others and to enable them to do the work required in coaching or supervision. Unless one creates a restorative space in supervision, little normative or formative supervision work will land.
Self-compassion is an essential component of professional life for all of us working in health and social care (all of us in general!). By investing time in ourselves, we invest in our capacity to work effectively and compassionately with our teams, our patients and their families.
Compassion practices are one way of ensuring supervision for healthcare professionals models and builds self-compassion – an essential way to survive the landslide.
- These are clinicians who have undergone coach training, so hold dual roles: active clinicians offering coaching to clinical colleagues.
- https://youarenotafrog.com/episode-75/ How to escape the drama triangle and stop rescuing people
- https://youarenotafrog.com/episode-75/ How to escape the drama triangle and stop rescuing people
- Brown, B. (2018) Dare to Lead. London, England. Vermilion.
- Kline, N. (2020) The Promise That Changes Everything: I won’t interrupt you. Penguin
- Neff, K (2011) Self-Compassion: Stop Beating Yourself Up and Leave Insecurity Behind. William Morrow & Co
- roctor, B. (2008). Group Supervision. 2nd ed. London: Sage.
- Proctor, B. (2010) Training for the supervision alliance: Attitude, Skills and Intention. In Routledge Handbook of Clinical Supervision.
- Peters, P. S. (2012). The Chimp Paradox. Vermilion
- https://www.youtube.com/watch?v=eMelRxXl3-M Closing the Compassion Gap: Andy Bradley
- Egan, G. (1994), The Skilled Helper, 4th edn, Pacific Grove, CA: Brookes/Cole
- Heron, J. (1990), Helping the Client, London: Sage