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Reflections from a session in the @empathymuseum at #Expo16NHS #WalkAMileInMyShoes via @HealthFdn

One of the best things I experienced at this years NHS Expo 2016 was the @empathymuseum …where I was invited to #WalkAMileInMyShoes via the @HealthFdn. It was rather strange to be invited into a giant shoe box, but nevertheless… Just like Alice in Wonderland I found myself uttering….’curiouser and curiouser’..

As I wondered in to the cozy shoe box to sit on the sofa, I was asked to put on a pair of shoes.. Theatre shoes…(See below)…

I walked around and listened via headphones to the man who had kindly donated his shoes and his story to this project. He was a specialist nurse working in A & E. He spoke about how he had to face the reality of death at work every day. Not only did he have to do this, he then also had to engage loved ones and relatives in incredibly difficult conversations and help them to make the best decisions in the darkest hours.

This nurse was able to celebrate the incredible gifts people were able to give as organ doners, and see joy in how a family was able to see a part of their departed loved ones go on… All of this was very uplifting…and there was no doubt in my mind that this nurse was indeed a superb example of the profession. However…as I walked on…I found my self wondering whether anyone asked the nurse how he was? How long could he maintain this uplifting approach whilst dealing with death and emotional pain on a daily basis? Would cracks start to appear?

I often see examples of how we celebrate this service and self sacrifice…and to nearly quote Paul Simon… every generation throws healthcare hero up the award charts!.. and so we celebrate this eternal culture of giving. I certainly empathize with this nurse, and greatly admired his approach to his work… He is a hero..but he is also very vulnerable, both psychologically and physically as he continues to give all of himself to provide the best service possible.

My worry is that the more we place service and sacrifice upon a pedestal…the further our heroes have to fall…

 

As you can see from the film above…this really is an amazing and thought provoking project, as those who visit are asked to write messages to those they now share a new found empathy with.

I would have liked to have walked a mile in all of these shoes…and perhaps some day I will have time to…as you can soon also experience this project online here. So as a lasting thought on this amazing project…I would like to repeat my mantra…which is…always be kind to yourselves… and each other….

Until next time 💛💙💜💚❤

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20 Ways to Create a Thriving #NHS workforce: #Leadership Lessons from @BSC_CCG

One head of Midwifery and one clinical matron have come to me this week asking for hints and tips about how they can support their staff (Great!) – They reported high sickness rates, clinical errors, high staff turnovers and stressed out staff. I am, as always, sorry to hear this. So I thought I would put together 20 hints and tips which have been proven to reduce mistakes, reduce complaints, reduce sickness and absence rates, improve retention rates, increase innovation and enthusiasm and create positive working cultures where staff are happy to be at work.

I have been on my travels again this week, one leader I met with in particular inspired me to learn more about how every NHS organisation can drive improvement through leading with compassion and actively supporting their staff in the workplace.

Cherry Dale is currently working within Birmingham South Central CCG (@BSC_CCG)….and her journey towards promoting healthy working cultures and staff well being is truly inspirational . I believe that her example now shines as an exemplar model for us all to follow. She doesn’t just talk the talk either…Her sickness rates are currently down to 0.2% in comparison with 4.44% average within the NHS, her staff engagement is high, recruitment and retention rates are high and the way her organisation can now innovate is amazing.

Hierarchy of needs - employee engagement

As I listened to Cherry’s words of wisdom, trying to take it all in…She pointed me to her latest published paper and her transformation journey -> How to get apples, not cactuses: an organisation fit for purposeMeeting the well being needs of staff and community. By Cherry Dale.

Cherry had a dream to create a “Very different sort of service”…Knowing that performance and well-being were “inextricably” linked, she looked to prioritise mental well being, and was keen to make sure that the needs and resources of staff as well as those using the healthcare services were “at the heart” of the way her organisation worked.

How can we all ensure that this comes to fruition? 20 Hints & Tips:

  1. Ensure that decision making is shared between all operational staff so that everyone is empowered to “Lead and act upon good ideas”
  2. Adopt the management style, promoted by the concept of the “Sunao Mind” (Untrapped, calm and highly adaptable)!
  3. Ensure that there are “No Dark Corners” – Share all knowledge and cascade it throughout, right from the top….This actively promotes ‘no blame cultures’.
  4. Embrace “Stand up meetings” Where staff are encouraged to share what went well, be down to earth and collaboratively share everything openly (30 mins in length).
  5. Imagine your organisation as a “Jigsaw” in which everyone holds a vital piece of the puzzle – encourage them to nurture this and take responsibility for it.
  6. Ensure there are no “Departments”, instead refer to “Natural working areas” so that boundaries are no longer in force and silo working becomes thing of the past.
  7. Ask “Who has the capacity?” to perform a task and “Who needs help?” – staff may be reluctant at first to share when they are at capacity, but in time the culture can metamorphosise into a supportive and emotionally intelligent culture, where staff are given extra support by colleagues whilst they are stretched to capacity.
  8. Ensure that staff realise that this is how you want and expect them to behave…You set the tone in communicating “This is how we do things here!”
  9. Erase the concept of ‘Grades’ or ‘bandings’ – If someone has the talent, motivation and capabilities to do the task…They can and should be empowered to do it! (Follow this with active talent management)
  10. See leaders as coaches and invest in training… for effective communication, ask coaching questions and avoid simply ‘directing’ people.
  11. Ban internal emails! – (A scary thought!) – This promotes conversations, movement and positive staff relationships.
  12. Promote open office spaces where senior staff are situated in the centre to promote open collaborations and discussion.
  13. Listen with interest and encourage staff to speak openly about concerns.
  14. Develop a ‘Human resources working group’ with members from each of your natural working areas to develop guidelines, policies and strategies with those at the top.
  15. Recognise and celebrate achievements, new ideas and acts of kindness.
  16. When staff are not quite themselves..Snappy…Tearful etc… encourage yourself and others to notice and check it out..”Is there anything you would like to talk about?…Feel free to come over and offload”
  17. Consider training all staff in the ‘Human Givens approach’…from this develop a staff wellbeing strategy, wellbeing days and events.
  18. Movable office furniture and bright colours inspire innovation.
  19. Link with the community and #GetInvolved with local fundraisers, initiatives and activities.
  20. Take this leap, make these changes and believe in them. Ripples will occur, people will notice…and your #NHS organisation can reap the same rewards.

As some of you will know… I have strong feelings about the term ‘Resilience’…But I do like this model below:

Resilience

 

Things to ask your team on a regular basis…

Have you laughed today at work?

Do you have someone you feel you can confide in at work?

Do you feel able to contribute to decision making?

Do you know what is really happening in your organisation?

Do you feel able to influence the direction of travel?

(Discuss your findings and create an action plan in response to results…Monitor progress!)

Spheres of control

“Don’t expect apples when you have sown the seeds of a cactus!”

 

Activity: Making the best of me…

1: Ask yourself how others can get the best out of you

2: Offer what you can realistically do

3: Communicate what inhibits your productivity with others

4: Actively describe what you need from others in order to thrive

 

Getting the best of me

A Sunao Mind: Having a sunao (untrapped or open) mind means being tolerant without selfishness, being open to the teachings of others, and being able to find joy in any circumstances. It also means being quiet yet dynamic, dynamic yet quiet. It is a state of mind that leads to the truth.

I hope we can all learn and embrace these lessons within our everyday lives. We know that the mental well being of #NHS staff directly correlates with the quality and safety of patient care…So let’s all create cultures in which we can thrive!

We are all leaders…so let’s all lead the way and leave our foot prints in the sand for those who wish to follow….

Until next time ❤

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Midwife Burnout: A Brief Summary

This week I have seen midwife burnout rear its head more than a few times. This is an issue close to my heart and one I dedicate my research to on a daily basis. Being a registered midwife and having practised through turbulent times myself, I know how it feels to give all that you have and yet forget to put yourself first at any time. You become a burnt out midwife, unable to give the highest quality or safest maternity care.

Here’s how it may happen…

 

The recent National  Maternity Review highlighted that midwives were more likely than any other professional group to report feeling pressured at work. Also, levels of staff stress in the NHS are the highest of any sector and staff consistently report a lack of compassion shown to them from leaders and managers within their organisations.

I find this incredibly sad…. We want to care so much for women and their babies…yet we fail to care for ourselves and each other.

The latest  work-related stress guidance cites one of my paper’s, which claims that “Midwives are entitled to a psychologically safe professional journey”… This is wonderful to see…but will we ever see midwives being cared for in equal partnership with the women and families they care for?

A colleague of mine recently noted that ‘as soon as we say that patients come first…we immediately devalue the staff’….

This got me thinking….and writing this blog post.

In the midwifery news this week:

I have come across the following articles in one way or another…

The experience of professional burnout can be one of extreme personal pain which some midwives feel they may never recover from. Despite global recognition of the destructive phenomenon of burnout, midwives may not understand what was happening to them. They can feel judged as managing their practices poorly, experience isolated feelings of shame, and feel unable to disclose their escalating need for help.

Young, C. M., Smythe, L., & Couper, J. M. (2015). Burnout: Lessons from the lived experience of case loading midwives. International Journal of Childbirth, 5(3), 154-165.

My 3 latest papers have addressed the issue of midwife burnout and psychological distress in great detail…I shall be publishing more shortly… for further reading see:

Pezaro, S. The midwifery workforce:  A global picture of psychological distress – ARTICLEinMIDWIVES: OFFICIAL JOURNAL OF THE ROYAL COLLEGE OF MIDWIVES 19:33 · MARCH 2016

Pezaro S (2016) Addressing psychological distress in midwives. Nursing Times; 112: 8, 22-23.

Pezaro, S., Clyne, W., Turner, A., Fulton, E. A., & Gerada, C. (2015). ‘Midwives overboard! ‘Inside their hearts are breaking, their makeup may be flaking but their smile still stays on. Women and Birth. In press.

Midwife burnout is rarely understood…Yet one thing is clear, we really do need to find new ways to support each other and look after ourselves for the benefit of all midwives working within midwifery profession, and the families we care for.

This week I will continue to write my systematic literature review which aims to identify the nature and existence of interventions designed to support midwives in work-related psychological distress, and their effectiveness at improving the psychological well-being of midwives.

Once this is complete, we will be one step closer towards effectively supporting midwives in work-related psychological distress.

Until then, look after yourselves…and each other.

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Reflections from the 4th International Well being at work conference 2016

wellbeingatwork

So…This week I have been visiting the wonderful city of Amsterdam to attend and speak at the 4th International Wellbeing at Work conference hosted by VU UNIVERSITY MEDICAL CENTER AND TNO.

This conference was great for networking, meeting people of like mind and learning about new research in the field of wellbeing at work. As I continue to carry out my own research into the psychological wellbeing of the midwifery workforce, I was happy to see other research work that will no doubt steer my own future work.

I was humbled to meet Christina Maslach who has done so much work in the field of burnout in healthcare and other staff around the world. The development of the Maslach burnout inventory (MBI) has been instrumental to the understanding of burnout in all types of professions. As such, I was very excited to share a quiet glass of chilled white wine and discuss further research in this field. There is so much to learn from you Christina!

The MBI Surveys address three general scales:

  • Emotional Exhaustion measures feelings of being emotionally overextended and exhausted by one’s work
  • Depersonalization measures an unfeeling and impersonal response toward recipients of one’s service, care treatment, or instruction
  • Personal Accomplishment measures feelings of competence and successful achievement in one’s work.

Christina Maslach is also now the editor of the newly found journal of burnout research. I hope to submit a paper to this journal in the not too distant future!

Having always had a keen interest in leadership, I was delighted to hear researchers from the university of Lausanne outline the key role that leadership has to play in the development of healthy workplaces. When we focus on the development of managers and leaders in the workplace, we essentially set the tone of the wider organisational cultures and behaviours. They lead the way and essentially show ‘How we do things here’!

wellbeing at work in leadrship

Equally, we must understand that health and well being at work and job satisfaction is more than a fruit basket! As we heard from ,  it became clear that interventions such as free exercise and health checks are insufficient in the development of a healthy workplace. They do no harm, yet we must look at new ways to promote healthy work cultures which set the tone of good workplace well being. I found this presentation very useful, and I will be reflecting upon the ways in which the findings of this particular work can be extrapolated to the #NHS workplace.

Also Lars L. Andersen is a really great guy 🙂

@LarsLAndersen

Although I found many of the presentations enthralling (and I cannot possibly list them all!) – I was particularly interested to hear researchers from  speak about mitigating employee silence. Through my own research I am quickly finding that health care workers can be reluctant to speak up about poor care, ill health and episodes of ‘impairment’. Occupational health and safety leading indicators are key to enable organisations to thrive.

The Top 3 Leading Indicators Organizations Should Adopt

Tracking and recording leading indicators is most useful to management when it tells the whole story of processes from start (or sometimes preparations to start) to finish. This makes it easier to gauge employees’ commitment to workplace safety and where to start from a training and communication perspective. Below is a short list of priority indicators to track.

  1. The more observations that employees and managers report, the more robust the data. One to two observations per employee on a weekly basis is excellent. This should not be considered a “tattle-tale” exercise, but a way to offer suggestions for improvement, recognition of underlying issues and maintenance needs as well as near misses.
  2. Employee engagement is critical for number 1 to work correctly. If all levels of the organization are paying attention to these things and talking about safety, a true safety culture will permeate throughout the organization. Best in class companies aim for 80 percent participation. This can ensure that many different aspects of your company’s processes are being evaluated and reported on.
  3. How long does it take the organization to act on observed deficiencies? Most corrections will be achievable very quickly. However, having more than 20 percent of these issues taking more than 48 hours to correct can mean that your company and management staff is not very effective at managing risk, which is a leading indicator in itself.

(Todd Hohn, Workplace magazine)

Mitigating employee silence

The mediation model of burnout provides a way of linking the quality of a nurse’s worklife to various outcomes, such as turnover. This will definitely be an interesting model to explore in my own future research where I look to find new ways to support midwives in work-related psychological distress.

Although there were a number of presentations which focused upon supporting the well being of health care professionals at work, none addressed the needs of midwives as a specific population to focus upon. This reinforces my own belief that in researching the support needs of midwives and the development of interventions to support them is still widely under researched. I hope I can conquer this niche area of very important research work to be done.

This particular presentation reflecting upon a meta-analysis of resources that contribute to the resilience of nurses was indeed fascinating. As I am currently working on a systematic literature review to explore the efficacy and existence of interventions to support midwives in work-related psychological distress, I hope my own work can complement new and emerging discoveries in this area.

resilience in nurses

My own presentation was very warmly received by an audience passionate about psychological well being of staff. I thank you all for your insights and questions in relation to my current work, I hope you enjoyed the healthy discussions and debates had by all.
wellbeing at work conference
The conference itself was buzzing with passion and enthusiasm from it’s delegates, and the hosts certainly took care of us with hydration, fresh and healthy food…massages during the breaks! (A first for me)… Strange characters invited delegates to the screening of a new health motivated movie (Some kind of space girl and a huge Postman Pat type character no less!
massages
…Also.. a health cafe was available for delegates to check  their blood sugar levels, cholesterol levels, blood pressure and BMI to make personalised and informed life changes to improve overall health. If only all conferences were so innovative!
Lastly, I wanted to reflect on how beautiful Amsterdam is at this time of year! The sunshine, flowers and beauty of this buzzing city really shone this week. The people of Amsterdam are also very welcoming and warm…Thank you for a wonderful and enlightening experience!
Amsterdam
I hope to see you all at the 5th Well being at work conference in 2018, France.
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The ‘Magic’ #Resilience Pill

There are no consistent definitions for what resilience actually is, yet I am beginning to actively dislike the word. It is beginning to sound as though it might be the magic pill everyone within the #NHS might need to take in order to survive. I am not so sure.

We don’t know much about resilience, yet it has been suggested that healthcare professionals need to be supported, not trained in resilience. I am inclined to agree.

Resilience building has a hidden cost in that “By introducing this focus on developing ourselves into “happy”, “positive” leaders one could argue that we are merely buoying ourselves away from, and in effect delaying, what is inevitable – the call to deal with the reality of our current state of play.”

Having ‘resilience’ puts the ownership of survival upon the beholder….. Does this mean that “You have had your resilience training (or ‘pill’) therefore you should be resilient now”? …. Will there be no room to show anything other than a new found ability to ‘cope’?

The NHS is a challenging place to work, and healthcare professionals are doing their best to survive and deliver the compassionate care that they wish to give. So should we be making the NHS a less challenging place to work? or be toughening up those who work there to become ‘resilient’ to adversities?

This is going to be a relatively short post, but I wanted to write down a few analogies that may help us all in thinking about what ‘resilience’ may really mean for us.

If you were being punched repeatedly in the face, would you:

A) Try to become resilient to the pain?

or

B) Try to reduce/stop the punching?

Perhaps a bit of both, but you see my point. The girl in the street who gets attacked does not need to wear a longer skirt, fight back harder or scream louder. Her attacker needs to stop attacking her.

The danger comes when staff feel that they should become more resilient rather than seek support for any pain they may be suffering. NHS staff health is vital to safe and effective patient care, and we would all like to see staff engaging happily with their work.

Yet perhaps the ‘Magic’ #Resilience Pill may actually be the placebo that masks our incredibly valued sensitivity as healthcare professionals.

It has been suggested that:

“The notion of resilience in midwifery as the panacea to resolve current concerns may need rethinking. Resilience may be interpreted as expecting midwives ‘to toughen up’ in a workplace setting that is socially, economically and culturally challenging. Sustainability calls for examination of the reciprocity between environments of working and the individual midwife.”

Whatever the case, it is time to be kind to each other. Always.

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The #WoundedHealer a reflection on #resilience #empathy #Support & #compassion in the #NHS workforce

Last week I attended the Wounded Healer – Helping Each Other to Care in the Modern Health Service conference on Tuesday 15th September 2015. I have a certificate to prove it and everything 🙂

I have spent the whole week reflecting on this conference, which brought together many experts who are passionate about exploring the plights of the wounded healer, and supporting those in need to care compassionately in challenging healthcare workplaces. There were also many who shared their own experiences of being a wounded healer (Including me)! Many had left the profession, moved to another part of the profession, or were still struggling to cope in challenging times. These stories were powerful, moving and also uplifting, as we also heard many stories of recovery. The main challenge of the day was of course focused upon finding new ways to help each other in practice to care compassionately in the way we all want to when we enter the health profession as ‘eager & excited puppies’ wanting to change the world.

This conference was facilitated by the practitioners health programme (PHP). The NHS Practitioner Health Programme is an award winning, free and confidential NHS service for doctors and dentists with issues relating to a mental or physical health concern or addiction problem, in particular where these might affect their work. The conference was also led by the Medical Director of the PHP, Dr Clare Gerada (). Clare is one of the advisors to my own research project, and I always draw so much strength from her knowledge, passion and wisdom. I am sure I will be consulting clare again once my Delphi Study has drawn its conclusions.

One of the highlights for me was meeting Professor Jill Maben, Director of the National Nursing Research Unit at Kings College London. Her work focuses upon the workforce issues facing today’s nursing populations (). Jill disclosed that she had left clinical practice as a result of unhealthy levels of stress in the workplace. She outlined to all of us her own work in discovering how new nursing students are indeed ‘eager & excited puppies’ wanting to change the world. These students quickly then realize that these dreams may never become a reality in the current working cultures of the NHS. As a result, they may choose to give preferential treatment to ‘favored’ patients or ‘poppets’ (Maben et al, 2007). I myself was privileged to finally make contact with such an inspiring research team.

We also heard from Professor Ivan Robertson, Mr Julian Lousada, Mr John Ballatt & Dr Penny Campling who all spoke about the importance of intelligent kindness, compassion for one another in the workplace and about how challenging workplace behavior may actually indicate a deeper pain. How do we cope? Do we deflect our pain on to others?

My thoughts were “Unkind people are unhappy people” and perhaps this is why we are seeing a lack of compassion between colleagues in the workplace. Those who display adverse behaviors need support too. There were certainly some stories of challenging workplace behaviors that suggest that this might be the case.

It was suggested that NHS staff enjoy hard work in their profession of choice. But this demanding work is only satisfying if it is matched by adequate support, resources and control.

This was followed by reflective sessions where professionals shared their own experiences, suggested advice for others and new forms of support. I think I was the only midwife there, and I am still concerned that there is little focus placed upon the well being of other nursing professions. I always find it cathartic to reflect among my own kind. I may have been the only midwife, but we are all one big professional family. This is my tribe. The people that understand and can empathize with the wounded healer. I hope that our insights can propagate among those who need it most.

The workshops that followed included:

Dr Derek Chase – Mindfulness and its Benefits

Dr Jane Marshall- The Addicted Professional

Dr Caroline Elton – Under the White Coat

Dr Peter Ilves and Mr Nigel Praities – GP’s, Resilience and Burnout

Mr Gary Marson, Dr Clare Gerada and Ms Pip Hardy – The Wounded Healer

Ms Debbie Sandford – Schwarz Rounds

Although these workshops largely focused upon the experiences of GP’s & Doctors, I could consistently relate the issues being raised with any other healthcare professional to a higher or lesser extent. The issues remain the same in any healthcare profession.

Along with the health practitioner programme, the  were referred to as a valid source of support for health care professionals. Schwartz Rounds are a multidisciplinary forum designed for staff to come together once a month to discuss and reflect on the emotional and social challenges associated with their jobs. The rounds are designed to offer emotional and social support for staff – not look for clinical outcomes.  Yet my concern is that these rounds require face to face talking and the time to attend a meeting at the planned time and location. I hope that the online intervention I intend to build in order to help midwives in distress can compliment these rounds in supporting all health care professionals in time.

For more information and reflection upon this conference, I would like to direct you to this blog post by Jonathon Tomlinson, as it holds some great references to other reflections and narratives in relation to the wounded healer.

I would particularly like to quote this from his reflective blog “There is a distinction between strength – to carry on regardless, and courage – to admit ones’ vulnerability – which is key to overcoming shame.”

It concerns me that the NHS may indeed be unwell. I reflect lastly upon the NMC Code of professional conduct which states that nurses and midwives must: 8.7 be supportive of colleagues who are encountering health or performance problems. However, this support must never compromise or be at the expense of patient or public safety.  We are in fact duty bound to look after one another for the safety of patients and the public.

So be excellent to each other.

Always.

Maben J, Latter S, Clark JM. The sustainability of ideals, values and the nursing mandate: evidence from a longitudinal qualitative study. Nurs Inq 2007;14:99–113. doi:10.1111/j.1440-1800.2007.00357.x

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What is the Future of Psychological Support for #NHS Midwives? My interview with @MidwifeDiaries

This blog was originally posted by Ellie from www.midwifediaries.com on June 2, 2015. We spoke in May 2015 about my research project and the issues surrounding midwives (and student midwives) in psychological distress.

What’s The Future Of Psychological Support For Midwives? Interview w/ Sally Pezaro
She wrote :”Who is this researcher?”

This was me, a few weeks ago stumbling across a blog. This woman was sharp, driven, and had all her energy focussed on supporting the mental health of midwives.

She really got how unchallenged the assumption is that midwives are ok to keep going 24/7/365.

Sally Pezaro is doing her PhD on supporting midwives in psychological distress. Her project is exciting, and if it gets launched, will be something we can all use to keep healthy.

In this interview, we talk about why it’s so important to look after midwives, bullying in midwifery, and some strategies for mental wellbeing.

Most awesome quote from this interview: ‘Don’t give everything you have until your batteries run out. Yep – must put that on twitter.

Here are the links we discussed, ’cause I bet you’ll ask!

What’s Sally’s doing is so brilliant because she’s noticed something that is wrong in midwifery – and is doing something about it. Her project reminds me of that quote:

“Be The Change You Want To See In The World”

It’s so good to know that we do have researchers on our side, trying to make things better.

Now, Sally and I would love to hear from you. What’s your answer to the question I posed at the end of the interview?

“What do you find most challenging in looking after your mental health as a midwife, and what do you think could be changed to help with this, both on an organisational trust level, and on a personal level?”

Thanks so much in advance for all the kind, insightful and inspiring comments that are left. I’m excited to hear what you find hardest, and what could help you look after your mental health better.

As always, thank you for your time and attention, sharing and being so brilliant. MidwifeDiaries is turning into an incredible, supportive place for midwives, and I’m so grateful.

Ellie xxx

-> I would also like to add a link to the newest NMC Code (2015) as midwives can now use the power of the code to challenge psychologically unsafe professional behaviour in the workplace. The code now states that midwives must be supportive of colleagues who are encountering health or performance problems. Midwives also have a duty to care for themselves under this new code, so please do not feel guilty for giving self care. We must all work to create therapeutic working environments….

Five experiences are judged necessary for health. Primary emotional development, attachment, containment, communication, inclusion and agency. These can be deliberately recreated in therapeutic environments to form a structure for ‘secondary emotional development’. Failure to recognise the importance of these qualities of an environment can cause unhealthy, or frankly toxic, psychosocial environments in various settings (Haigh, 2013).

Haigh, R. (2013) ‘The quintessence of a therapeutic environment’, Therapeutic Communities: The International Journal of Therapeutic Communities, 34 (1): 6 – 15.