Positive about Change?

'Learning is the discovery that something is possible.' 

Fritz Perls

'The problems of the world cannot possibly be solved by skeptics or cynics whose horizons are limited by the obvious realities. We need men who can dream of things that never were' 

John Keats

Dr Martin Seligman is a Professor of Psychology at the University of Pennsylvania. He is famous for his work in the field of Positive Psychology. This school of psychological thought doesn't seek to replace mainstream psychology but complement it through the study of what gives life meaning and what makes it worth living. It asks how we can extend and amplify the good that is already working in our lives and shining the light on our creative assets and seeking their growth and unfolding.

One of the authors at the beginning of his academic career attended a presentation where Dr Seligman outlined his early ideas about the need for Positive Psychology. Dr Seligman received a series of challenging questions around 'why bother with all this positive stuff?', Dr Seligman replied that he had to because he was a born pessimist. He said he needed a practice that helped him see through problems to positive options and be more optimistic about outcomes. His natural temperament would lead him to be locked in the problem. He needed a key to unlock this process and move to another place to address the issue. This echoes well the comments of Einstein and Jung that we often cannot solve problems on the same level of consciousness that generated them. We need new spaces and thinking to break the code of the problem.

This positive, more optimistic approach echoes much of what we see crossing our services and on forums like Twitter. People and networks are sharing fresh, kind and affirming ways of being and doing as the future framework for change. These new movements offer such promise, potency and energy. Yet it is not always an easy walk although a much needed one, especially if we are talking about the deep, sustainable change that so many of us see as possible and work so hard to achieve. All too often we have experienced changes in services that only touch surface structures, policies and procedures rather than going to the heart of the issues. And sometimes people propose a ‘be positive approach’ as part of these initiatives, failing to really appreciate the complexity of issues, acknowledge the scale of the challenges or engage the difficulties that the people involved deal with on a day to day basis when they see the potential of what could be possible in the face of a reality that seems intractable.

The kind of positivity Seligman is promoting has nothing to do with creating false positive-ness that can only ever skim along the surface of change. Rather, a Positive Psychology approach invites us to name the problems and the pains and see how we can learn from them to work them through in constructive and compassionate ways. Positive Psychology offers much for us to learn. It is not just about being positive, its about engaging with the complexity of a challenge and bringing positive approaches to working with it. Authentic listening, mutual support, empathy, knowing we don't have all the answers, a commitment to deep and open dialogue and the creation of new ways to think and do health and care is the DNA of these new movements. At it’s heart is the belief that all of us have tremendous goodness, gifts and potential. We believe that is from the activation of these wellsprings that the solutions and new forms of service will emerge.

- John Walsh. York Street Health Practice, Leeds Community Healthcare NHS Trust

- Dr Andrew McDowell  http://www.theperformancecoach.com

(The authors of this met recently at an initiative of the NHS Health Trusts and Public Health in Leeds. They have brought Health Coaching into the city so we can look at and change the quality of our health conversations with patients. The old model is where the patient is the passive recipient and the clinician the expert. This is a move to a new terrain where both are experts and co-create health plans and solutions together. At the heart of this approach lies a view of people as not problems but as people with assets, gifts and potency. This more humanistic and positive model offers great promise to people and the city.)

Staying safe and sane at work

This title may surprise some readers. The words 'safe' and 'sane' are probably not words we may use a lot to do with work. When we say 'safe' we mean a state of feeling good or at least OK - emotional wellbeing. Not feeling threatened or capsized. When we use the word 'sane' we likewise refer to being balanced, stable and established. We use these words as there are currents, dilemmas and events in the workplace that that really do challenge our sense of safety and sanity. When people use phrases like 'Work is driving me mad' you get an idea of where we are coming from. So how do we maintain our safety and sanity in a world and work that is constantly moving and changing? 

We would like to offer this article to look at three aspects of the problem.

Outside Work
There is a  symbiotic relationship between work and our life outside work. One affects the other. In fact what happens in one can overshadow and sour the other if we are not careful. Therefore, can we maintain our work sanity and safety by what we do outside? If people have positive activities outside work this gives an powerful resource to deal with work stresses and difficulties. Each will have our own practices to achieve this. The  list is long - walking, swimming, working out, meditation, reading, dancing and so on. What we think they all have in common is that they take us out of ourselves or maybe away from our problems and actually into our authentic selves. In getting this bit right we create a good 'work problem' detox programme as well as finding ways to grow and develop. If we can get side of life right we have somewhere to go and be re-energised and refreshed. The business world is building 'quiet rooms'into their offices and building mindfulness and meditation into their work programmes. They realise the need and are prepared to bring it into the office and service space. 

Inside Work
   In work we may face lots of things that can make us feel upset and stressed. If these continue and worsen it can start to impact us on different levels - sleep, patience, hope, certainty, physical, emotional and mental levels. There are work services to support staff such as HR, staff counselling, coaching and talking to one's trade union. Usually when we have a problem there are three things we can do. They are all simple and well known. The strange thing is that we often don't do them or only do one or two but not all three. We'll mention them now as ways to start resolving what may challenge our work sanity and safety. They are
(1) See the Source - think and reflect on what is causing the problem. Don't focus so much on the effects but what is the cause.
(2) Speak to another. We can get things wrong and most of us benefit from reality checking. It's easy to see  just through an emotional lense or a fear lense. Another perspective from a colleague with insight can really help.
(3) Act. Decide that you have a choice here. Decide what you need to appropriately do and take the first step.
 We realise fear, busyness, tiredness, etc all get in the way here. But if we don't act things won't change. This path can certainly demand courage, resolution and support but the only way to a resolution is through addressing the issue. In addressing it too it is good to think of how we might manage this. How we need to be polite, professional and clear and what support we will need. This road is often difficult. It is also a road through which much valuable self discovery and self worth can emerge.

Inside Ourselves
The third of our three areas is us - ourselves. It is an admission that we can contribute to a problem or an issue at work that causes work to be a place of threat and stress. It is where we stop blaming the economy, the manager or a work colleague and own our responses and approach. We may have a number of emotions or states that we don't like but which play a part. These may include feeling very vulnerable and scared, anger. wishing to undermine others, ego, jealousy, hopelessness and passive aggressive features. We are not equating these states as some come from different places. We note them to recognise that we all need to realise the stones or pebbles we are throwing into the work pond. We may not always recognise our behaviour patterns or how we play out situations. We may when confronted by another or by our own awareness say "Well that's me! That's the way I am wired. I can't change."

Looking at our inner states will mean us facing parts of us we don't like or even deny. Yet this is part of the journey. Facing ourselves as we are is the road. One of the most eminent psycho-analysts in history Carl Jung said, “Where we stumble and fall is where we find pure gold.” Seeing and naming the problem is the fundamental.  Putting this together we would respectfully suggest a programme for positive and real change begins when we 

(1) See the inner issue

(2) Accept it as part of us but recognise that we are not pieces of wood or stone. We have the freedom to change. Accept that we can be different

(3) recognise that change will make us better people and possibly our work life better for ourselves and others. 

From here we can start to look for what we need to do to change and grow. This might mean using counselling or other disciplines. What this adds up to is a new perspective. It is a recognition that none of us is perfect and that growth is a wonderful and tremendous possibility for us all. This is a transformation that can work good in other areas of our life other than work. John remembers many years ago visiting a client in prison outside of Leeds. He was there for a violent crime. In the visit he was angry about what had happened to him. John then visited a few weeks later. He was in a very different frame of mind and outlook. He had been visited in the interim by a nun who worked with homeless people in Leeds called Sister Eileen Carroll. Eileen, who died a few years ago, was such a positive force for good in the lives of homeless people in this city. She had spoken to him about the need to let go and how holding onto this was only really hurting him. The words must have sunk into our friend's heart and mind as when we visited him he accepted he was in prison for a crime he had committed, that he was to serve his time and wouldn't hold any grudge. And that's what he did. He's never been back to prison. He had faced his own inner feelings and state, listened to a wise person and then let a new pathway open us which he followed. Change is always possible and we hold in our hands the keys to open the door to change. Change should always be infused with wisdom and patience. We cannot change things or particularly ourselves overnight. We can however take the first step right now to a better life and us if we wish. Let's take it. 

Lisa Falkingham. Service Improvement Team. Leeds Community Healthcare
John Walsh. York Street Health Practice. Leeds Community Healthcare

Holding it all together

This post starts with the story of a friend of ours. She works in a large global business and her name is Pat. Pat has worked there for seven years and is presently in an office which works with staff counselling. She loves her job and finds it deeply rewarding. She says, "I am so lucky to be in a place where I can spend time with people who make a difference every day and I really believe my added value comes in supporting others." The concern for Pat is that she may be moved back to her old department. This wouldn't be a disaster but will take Pat away from where she has found such growth and life. Her current post is described by her as a ground for exploring and discovering for herself and others what she can offer. Her words express this powerfully, "My role has enabled me to flourish and pursue my passions...using my skills to support others to reach their potential, recognise their strengths and skills and also to identify needs...Honesty, difference, challenge, enthusiasm, resistance have become my food, my motivation. Where there is energy there is hope and potential." Pat faces three challenges here. The first is what happens if they move her. The second is how does she manage the process until the decision comes through. The last concern is are these thoughts wants or needs? These are deep questions. In this post we will offer a possible answer to our friend. In it we will try to touch on what is essential here. We hope there might be life lessons here for us all.

The first worry is the big 'What if'' question. In Pat's case it is a 'may well happen' statement. A number of things are interesting here. It's amazing how we often we can go to the worst possible place when a change is a possible outcome. We can worry and think the very worst will happen. Why do we think the worst? Why are so many of us more likely to think the worst than the best? We think a possible answer is that we haven't reached that place yet of holding our life and it's determination in our hands yet. A place called inner freedom. In history we often hear about the right of countries to self determination. It was one of the big arguments against the large Empires. Countries must have the right to govern their own destinies and futures. It's not always the case that we exercise this right with ourselves. We either deny we have any power or give it away. When we worry in such a way we are really saying 'I have no power. I can't control anything here. I have no choices.' The truth is that worry is very common and a paralyzer of our life and energies.

The problem is that it is a mental prison and we need freedom. We need to be someone who owns their life and destiny. Not easy. Maybe big tough decisions but that is what freedom entails and gives. It gives the possibility of living in a new, fresh and abundant way. Pat realised this and sought places and strategies to not walk in to these dark domains of worry and fear. She accepted what might happen and that if it did she would have choices to make. She would make them and take the next step by placing one foot in front of the other. If what she didn't wished happened she would work with it. She might decide to leave or stay. The decision actually became secondary in her life. What mattered was how she got there. It had to be in a way that she owned her dignity and life. The journey became the key focus.

The second thing was how was she to manage her process during these tough months of not knowing. Her words are revealing here. Pat talks about "I can chose to enjoy today; I can see what I want and I can strive and do what I can to work toward that. I've talked to people in the organisation. I realise is that I get strength, not from the talking but from the doing." Pat knew she couldn't control or predict the future. She knew to live in the future was only possible in her head. What she did have - concretely and really right in front of her - was today. She could take the day and make it into the best possible. Pat was actually a difference maker because she focused on the present and made it the best.  It's not always easy but is the way. Of course we have to plan and make decisions. However we always do that in the present for the future. We are not mean't to live in the future. Paradoxically by owning herself and the present Pat was making the future. What she also saw was that to let go of the fears is freedom but feels like awfulness to start with. Pat believes all will probably be well. She does this because she has seen it work out well a thousand times before. She also knows that her worry often tells her untruths. If we thread these strands together we find a self ownership of herself in the process, a focus on the present and a belief that things would somehow come around. She lived in what might be called a state of hopeful tension. There were moments of worry and unrest but also hope and a look to a future while being anchored in the now.

The last thing was Pat's questioning of her motives and reasons. Was this needs or wants? It's a good question. Sometimes what we call need is actually just what we want. How do we tell the difference? One suggestion might be that a need is a thing we require at this moment for our deep development and growth. It's something which is essential to our becoming who and what we are. It may not be essential tomorrow but it is today. Without it our authentic growth would come to a halt. Or perhaps key aspects of it would. Pat described her role as "a role which has enabled me to flourish and pursue my passions ...using my skills to support others to reach their potential". It sounds like Pat needs this role as it helps her see and release her skills and gifts. The big challenge to Pat will be that if she is moved will she have the same space to grow and flow? Kate Cowie in her amazing book 'Finding Merlin. A Handbook For The Human Development Journey In Our New Organisational World' makes a key point on this. She writes that, "if our working environment is not providing us with the stimulation we need - our responsibility to ourselves is to seek an alternative place of work, one which will foster ( rather than hold in abeyance or,worse, stymie) our ongoing growth." We can confuse our needs with our wants usually due to powerful emotions dominating the picture. We can also fail to note our needs. This brings us back to where we started - the giving away of our power. Our needs are important. They call and grow us. We shouldn't ignore them. In a busy 24-7 world where everything is go this may sound like luxury. It's actually life itself.

 Living with uncertainty isn't easy. Holding it together can be real challenge. Pat shows us not only that it can be done but one way how it can be done. Some of the best wisdom is that found in the market place and there where the Pat's of this world live and teach the rest of us if only we will stop and listen.

 Lisa Falkingham. Service Improvement Team.Leeds Service Improvement Team

 John Walsh. Support Manager. York Street Health Practice. Leeds Community Healthcare NHS Trust      

Hearing the homeless - working for best services

We all favour client participation, joint working with key partners, having a strategic vision and making a difference. But how do we do it? How do we make sure one of the key elements is not lost or ignored? Some may say there isn't always an easy answer to this. Some recent work between Healthwatch Leeds and Leeds Community Healthcare / York Street Health Practice offer a good model of how this can happen. In this blog two of the participants describe the work and its lessons.

Healthwatch Leeds is committed to a great vision - 'Healthwatch Leeds gives people a powerful voice on health and social care services in Leeds and beyond. Healthwatch Leeds helps the people of Leeds to get the best out of their local health and social care services, whether it's improving them today or helping to shape them for tomorrow. Healthwatch Leeds is all about local voices being able to influence the delivery and design of local services. Not just people who use them, but anyone who might need to in future'. Healthwatch is the official body that represents patient voice and concerns in the field of health and social care. Its work is vital and everybody in health and social care should actively and positively welcome it. 

Healthwatch Leeds contacted York Street Practice as it needed to produce a report on homeless people and health in Leeds for the Health and Wellbeing Board. The two agencies had already met and were both committed to the provision of the best patient care and experience possible in the city. In the conversation about the report, York Street decided not to host the event for the voice of the homeless to be heard. The reason was we wanted a neutral place where our patients could speak and be as open and honest as possible. We discussed with two key partners in the city - St Anne's Resource Centre and St George's Crypt. They agreed to host the event where Parveen Ayub, Community Project Worker, and volunteers at Healthwatch could meet homeless people and talk to them about health issues and services in Leeds. This work was supported by the agencies involved. It was written into a report that was presented to the Leeds Health and Wellbeing Board. The report looked at difficulties homeless people encounter when accessing health and social care services and the impact it has on their health and well-being. The report supported outcome 5 of the Leeds Joint Health and Well-Being Strategy 2013-15. In this way the voices of those who have few to speak for them was presented to the key strategic health and social care body in Leeds. The homeless were heard! 

To us this linked together many key needs. These include; positive partnerships between health and patient groups, allowing the patient to be heard in neutral but supportive environments that they trust, for patient groups to reach out to where people are, for those without power and a voice to be supported so their voice and needs are heard and for the leading authorities in the city to have this presented to them so they can feature it into their work for the whole city. This circle approach - from patients to strategy - from patient groups to health services - from the creation of positive space where dialogue can occur to changes in the system - all offer great hope and models of how we can work. 

This is how we can make Leeds the best city for health and wellbeing. It's a tremendous thing that we can work to make sure that not only the poorest receive healthcare the fastest but that their voice can be heard quickly through initiatives such as this. This might be the first time in the UK that Healthwatch and a health service have written a joint article celebrating joint great work and offering a key model of how we can work for the vulnerable. If it isn't the first time that's good. If it is, that's something good too. We see what we have tried to describe as best practice for those most in need now and a promise what future work can look like. Hearing the homeless and vulnerable is how we work for best services.

Parveen Ayub -  Healthwatch Leeds

John Walsh - York Street Health Practice

Culture Change in the NHS

Leeds Community Healthcare is currently working in partnership with NHS Employers and Southampton University on a project to understand and support culture changes in the NHS. The project will run until November 2014 with specific outputs on tools for development of new cultural paradigms across the health economy.

The project team comprises of Catherine Hall (Service Manager for Specialist Services), Caroline McNamara (Senior Clinical Lead), Julie Mountain (Head of Adult Neighbourhood Services),  Julie Thornton (Development Lead) and myself.

Much emphasis has been placed on 'culture change' over the past couple of years in the NHS and we have seen forensic examination of system failures across the NHS. The outcome of this has immediate impact on patients and their families and the importance of putting these terrible events right is critical. One of the more astonishing and distressing facts to emerge from the Francis Report for example was the number of instances of not only poor care, but inhumane care. Patients were left lying in their own urine, or were left for hours without food or drink. Psychological studies have helped to shed light on the mechanisms underlying inhumane behaviour, such as ignoring distress and harm to an individual, although it is worth bearing in mind that none of them were caring for vulnerable patients.

Particularly pertinent is the ‘bystander effect’, in which individuals stand by and fail to help a victim in distress. Relevant variables (see Fischer et al, 2011) include the number of bystanders present (more means it is less likely that a victim will be helped); the ambiguity of the situation (more ambiguity leads to less help); and the similarity of the victim to the bystander (the greater the similarity, the more likely that help will be offered). Research has also shown that pressing situational factors may readily override explicitly enounced value systems and beliefs, such that a person in great distress is ignored (Darley & Batson, 1973), something that could find parallels in busy clinical settings.

Also relevant is Philip Zimbardo’s Stanford Prison Experiment (Haney & Zimbardo, 1998) where those who were put in charge of prisoners subjected them to inhumane treatment that seemed to transcend all moral boundaries. Relevant issues are discussed by Miller (2011) and by Haslam and Reicher (2012). The latter’s findings indicate that a positive hospital culture of strong leadership in human values and appropriate peer support should help to counteract any negative tendencies.

The vast majority of NHS organisations run perfectly smoothly and cope extremely well under the pressures that are currently being experienced by staff.  When we hear talk 'in the system' of culture change what do they or we precisely mean? It’s useful to nail down a definition here:

"Culture is a set of shared, taken-for-granted implicit assumptions that members of an organisation hold and that determines how they perceive, think about and react to things (Schein 1992)." In other words it’s 'The way we do things around here'. 

In a recent accompanied visit with a District Nurse to one of the poorer districts within Leeds we visited an elderly couple. The patient we had gone to visit had the start of small ulcer around his bottom and the Nurse had visited to offer treatment and reassurance. We had gone only to see the man for treatment but it quickly became apparent that both needed some form of care. Whilst Elaine was attending to the 'real' patient I chatted to his wife. A large portion of what we both did that morning was not only attending to the patient’s clinical needs but also a whole range of social and psychological support. Most of that was through being interested, curious and listening to stories about their journey through life; where they grew up, which school they went to, what their parents did and noticing the pictures on the wall.  Each photograph telling a story about their lives, the histories of their families and how they had grown up in Leeds. 

Often with huge pressure on their time, nurses (and other care professionals) do this day in day out with care, compassion and attention. This is clearly technical clinical competence done with kindness. We could say that kindness is something, which is generated by an intellectual and emotional understanding that self-interest and the interests of others are bound together, and by acting upon that understanding. Human beings have enormous capacity for kindness. It is this essence that is at the core of our change work in LCH.

If we are to support the changes that are necessary and needed within the NHS we also have to be mindful and supportive about the millions of positive interactions that take place every day across the country. The danger is that we become embroiled in negativity regarding the terrible events such as Mid Staffs without paying attention to the amazing work that takes place. There are things that we are doing and can do provided they make sense to staff and patients and also connect to our values and behaviours.

Culture change is happening all the time and as a reminder of this we only have to look back to how things used to be.  The essence of what we stand for in the NHS will never change, this is the greatest of all platforms with which we can truly 'stand on the shoulders of giants'.

‘We are living in a world of change - the tempo of life has quickened considerably. The wheels of “possibility” in our world of nursing would appear to be turning more swiftly. Many hospitals have been enlarged and new departments have sprung up within them. There is a new look in many of the Wards and Nurses' Homes. Revolution is in progress, and like every transitional condition, it has an upsetting and almost bewildering effect on the various members of our profession. Is it not all the more necessary, therefore, that everything possible should be done to ensure stability and continuity? But one of the main foundations is a sense of community, and all efforts should be made to foster and strengthen the feeling that we are all part of a whole, with a common centre and mutual purpose.’ (The British Nursing Journal September 1951)

Steve Keyes, Head of Organisational Development

 

References  

Darley, J. & Batson, C. (1973). ‘From Jerusalem to Jericho’: A study of situational and dispositional variables in helping behaviour. Journal of Personality and Social Psychology, 27, 100–108.

Fischer, P., Krueger, J., Greitemeyer, T. et al. (2011). The bystander-effect: A meta-analytic review on bystander intervention in dangerous and nondangerous emergencies. Psychological Bulletin, 137, 517–537.

Haney, C. & Zimbardo, P. (1998). The past and the future of U.S. prison policy. Twenty-five years after the Stanford Prison Experiment. American Psychologist, 53, 709–727.

Haslam, S.A. & Reicher, S. (2012). Contesting the ‘nature’ of conformity: what Milgram and Zimbardo’s studies really show. PLoS Biology, 10, e1001426.

Miller, G. (1969). Psychology as a means of promoting human welfare. American Psychologist, 24, 1063–1075.

Schein E (1992). Organizational culture and leadership. San Francisco: Jossey Bass

The British Nursing Journal, September, 1951.