Helping the NHS workforce navigate COVID-19

All change please! Eleanor Bull says behavioural science should help the NHS workforce navigate COVID-19

Over these past few weeks, we have all been making profound changes to our daily lives. This is no less the case for our NHS workforce. Many in senior roles are under pressure to make and implement complex new workforce plans, design guidance for frontline staff, redesign services and think creatively to solve logistical issues and mobilise scarce resources within unprecedented timescales. An understanding of behavioural science is vital to help decisions makers make good choices and implement change effectively. During 2016-2018 colleagues Dr Lucie Byrne-Davis, Professor Jo Hart at the University of Manchester and I helped four NHS clinical teams to transform their practice using behavioural science. As part of the dissemination of our Teams Together programme, we produced several easy-to-read briefings, short animations and other e-learning materials on using behavioural science to change practice, available on our website here.  From these and thinking of the current crisis, there are several suggestions NHS leaders and health policy makers can consider:

• Make space for System 2 thinking

Psychologists distinguish between two types of thinking and decision-making, sometimes called ‘System 1’ and ‘System 2’. In normal circumstances, a large portion of our everyday behaviour is habitual, driven by System 1 thinking. We take similar decisions and actions frequently, automatically, without conscious effort and in response to cues in our environment. We use System 2 thinking less frequently. It involves marshalling slow, effortful decision-making processes in the frontal lobes of the brain to make new, evidence and values-based decisions and plans. System 1 thinking is evolutionarily older, and is designed to help us act quickly to keep us safe and out of danger. However, it is prone to thinking errors, known as cognitive biases. System 2 thinking tends to lead to well-reasoned, evidence-based decisions, which takes time and is difficult under conditions of tiredness, time pressure, uncertainty, high emotional arousal or high stress. Sometimes both thinking routes would lead to the same conclusion, but not always.

Most would agree that System 2 thinking is needed when decisions concern the safety and wellbeing of thousands of NHS workers and patients, but how is this possible given the strain leaders are under? Even in this time of pressure, health policy makers and NHS leaders must make space for System 2 thinking. This includes self-care practices such as maintaining healthy eating, sleep hygiene, social support and exercise to help cope with stress. Moving to a new physical space to make a key decision may also help, such as brainstorming during a daily walk. It can also be helpful for decision makers to prompt their own System 2 questions (what does the evidence say? What information do I need? What are all of the options? Who can advise me? What are my team’s ideas and concerns? What could be the unintended consequences of each option?) and being alert to System 1 type thinking (What do I usually do? What will please a vocal group around me? What is the quickest/easiest option?). Leaders who make well-reasoned System 2 decisions and involve teams in change will find better, streamlined solutions which teams will be more prepared to rapidly implement.

• Specify the behaviour changes needed

Once decisions are made, just like with messages for the public, guidelines for the NHS workforce should be behaviourally specific and motivating. This means clearly stating who will do what, where, when and how and why this is an important, positive step to take. This can be complex taking into account many situations a worker may find themselves in and the variety of changes needed.  For instance, teams may be used to noticing times when they need to wash hands when on the ward, but may not have thought about how guidelines apply to attending an emergency planning meeting in a local council office. Many staff will be working in unfamiliar locations or roles so extra behavioural information may be needed. Making all messages as clear and consistent as possible is useful. Specifying guidelines as an ‘if-then plan’ (if you enter a building, wash or gel your hands) can help guidelines become context-cued System 1 habits. Asking rather than telling where possible may help staff retain their sense of agency in a high stress environment.

• Ensure people have capability, opportunity and motivation

Leaders must understand the psychological influences on behaviour to be able to support workers with changes. These have been summarised in a simple framework called COM-B as Capability, Opportunity and Motivation. To be able to do a new behaviour, staff must have the capability (knowledge and skills), the opportunity (e.g. social support, time and equipment) and motivation (a favourable attitude and routines to support it). If one of these is missing, change cannot happen successfully. It is essential to listen to staff to find out influences on behaviours and other needs. As well as the urgent need for equipment, these may include further training to increase capability or leader support to enhance motivation, whether through persuasive communications or thanks and encouragement to continue new behaviours.  Staff are working in new roles, under high-pressure conditions of personal risk, whilst socially distant from usual coping networks. NHS policy makers and leaders have a vital role as role models to promote a positive working environment and explore and overcome rather than dismiss barriers to practice change.

In summary, making headspace for System 2 decision making, creating behaviourally specific guidelines and addressing psychological barriers to behaviour change will help policymakers implement change at scale and pace. Using behavioural science in this way can support the NHS workforce to effectively and compassionately navigate the many challenges ahead.

Eleanor Bull is a Senior Lecturer in Health Psychology at Manchester Metropolitan University and a Health Psychologist at Manchester University NHS Foundation Trust

If you are from an NHS team and would like behavioural scientist expertise during the pandemic, health psychologist volunteers can help. Please get in touch on Twitter @HealthPsychX or by email healthpsychologyexchange@outlook.com

Key References

• Bull ER, Byrne-Davis LMT, Swift J, Baxter K, McLauchlan N, and Hart JK. (2018). Exploring what teams mean by ‘culture’ when implementing new models of care. Int J Qual Health Care, mzy200, https://org/10.1093/intqhc/mzy200
• Bull, ER., Hart, J. K., Swift, J., Baxter, K., McLauchlan, N., Joseph, S., & Byrne-Davis, L. M. (2019). An organisational participatory research study of the feasibility of the behaviour change wheel to support clinical teams implementing new models of care. BMC health services research, 19(1), 97.
• Kahneman, D. (2011). Thinking, fast and slow. London: Macmillan.
• Michie, S., Van Stralen, M. M., & West, R. (2011). The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science, 6(1), 42.