St Emlyn’s Hierarchy of Wellbeing

Estimated reading time: 7 minutes

Wellbeing is a very ‘trendy’ word in Medicine and seems to be the focus of many educational sessions (or even days), with some departments forming ‘Wellbeing Working Groups’. However, in this post please don’t worry that you’re about to read about the value of yoga and badges: quite the opposite.

Many of you will have heard of Maslow’s Hierarchy of Learning needs, read Simon’s excellent post and seen this graphic.

I would like to propose an amended version of this which could form the basis of a departmental wellbeing plan. Remember that you need the lower levels in order to build the levels above. My version focuses on what I believe truly makes a difference to the happiness of both individuals and teams.

The St Emlyn’s Hierarchy of Wellbeing

Physiological

This is by far the most important level and too often neglected. It is the foundation on which everything else is built, yet the factors within this are often taken for granted and rarely considered. For example, my own (large) Emergency Department (ED) has only four toilets that are shared between the whole staff team. You cannot even guarantee that there will be toilet paper.

You may think the items in this level are both obvious and easy to achieve, yet how many staff still struggle to be able to buy a hot meal on a night shift?

I would implore you that before you think about any of the higher levels these ‘simple’ items must be be sorted. This has to be the focus for the Trust Executive, working closely with the medical and nursing leadership. You simply cannot expect staff to function at the level required if they can’t get a drink of cold water during their shift (although the subsequent improvement in their hydration will make the absence of adequate numbers of toilets even more apparent).

Safety

We all need to feel safe. We all need to feel supported.

Safety can be in the form of physical safety: adequate security staff and plenty of PPE, or psychological safety: knowing that you will be supported both clinically and personally.

Violence towards staff is a real and continuing problem in Emergency Departments across the world and is completely unacceptable. No one should go to work in fear for their safety.

Personally, I would like to see Police routinely in EDs, both as a powerful deterrent and a very visible support to staff. When considering the cost to the NHS, this is miniscule in the face of a current staffing budget of about £50 billion per year.

We also need to feel clinically safe: that we are making good decisions about our patients. And this is where education comes in. This should not only be in regular ‘formal’ sessions, but be part of the very fabric of the department. Seniors should be as ever present as possible to offer guidance and support. Education is a vital part of the support system for staff and should be prioritised: cancelling teaching sessions or not allowing time to teach in the name of ‘seeing more patients’ is short sighted and naive. The recent push by the Royal College of Emergency Medicine for Clinical Educators (clinicians whose priority is to support and teach during shopfloor sessions) must be encouraged, not just for doctors, but for all members of the team.

Adverse Event Reports (or DATIXs) should only be completed when absolutely necessary: too often I have seen and heard examples of these being ‘weaponised’. All this does it create an environment of fear and blame (but cloaked in the facade of ‘patient safety’). Of course we need to report when things don’t go as well as we would like, so these can be addressed, but sensitively and but not at the expense of staff wellbeing (see also Esteem below).

Belonging

I’m afraid I do not believe in describing my work colleagues as ‘family’. For me this creates unrealistic expectations of what we can expect from each other (and our work as a whole). However, a sense of belonging is vital: that we all have a common goal and will do all we can to achieve this together.

We all need to know what is going on in our departments, and regular communication helps with this. A weekly email and monthly staff forum can disseminate information and help staff feel involved. Conversely, I do think that too much communication can be a bad thing. Too often contact groups and ‘reply all’ are used indiscriminately. If I am receiving an email I want to know that the content is pertinent to me and worth my full attention. All too often, important messages are lost in a forest of nonsense. Instilling a sense of belonging is much more than starting an email ‘Dear ED Family’…

Although it can sound cliched, we are all one team in the hospital. Conflict with other specialties is far too frequent and incredibly damaging. We know only too well of the effects of ‘negative emotional contagion‘ on not just the person receiving the animosity, but all within earshot.

How can a team possibly function when interactions often start with introductions using titles and not names? Where else in society would this ever happen? Medical Directors could improve wellbeing in a single stroke, simply by insisting that clinicians must introduce themselves with their actual name. ‘Hello my name is…’ isn’t just for patients.

Dare I suggest that a regular free social event for all members of the hospital involved in the care of acutely unwell patients could be a reallly good use of resources? It breaks down barriers and helps us see each other as human beings and not titles. It’s very hard to be rude to someone you have had a drink with. You could even combine it with education appropriate for all. You could even invite colleagues from General Practice…

This superb talk from Victoria Brazil about silos in healthcare is well worth 20 minutes of your time.

Esteem

I am often told that we all want feedback. The truth is that we all want positive feedback. We need to feel valued and appreciated, and this must feel genuine. We have got better (I think) at thanking staff and giving praise, but we can do this so much better. Instead of saying

“Thank you so much for your hard work today”

make it relevant to the individual and show that you have actually noticed what they have been doing:

“Thank you so much for your hard work today: I was particularly impressed with the way you recognised that patient had sepsis and made sure they received their antibiotics and fluids promptly. You made a real difference to their outcome”.

Of course, there are also times when we need to give feedback that is not positive, but done carefully this can also help the receiver to grow and develop (this applies to AERs/DATIX too).

The Extras

This is the area that I fear “wellbeing groups” and their ilk often focus on and I have deliberately left it blank. Of course, no one is going to complain about a free pen or coffee, but this really cannot be the focus. This can only come after all the other levels have been addressed. Too often I see initiatives in this category that are superficial at best and patronising at worst. Wellbeing is the whole package and cannot be fixed with a tray of doughnuts. Or a badge.

What next?

We would love this post be start a conversation about what we can practically do to improve staff wellbeing. What would be in your hierachy of wellbeing? How can we deliver this? Over coming months we hope to develop this into a St Emlyn’s resource that can be used as a readily available reference for all those that are looking to support their teams and themselves.

References

Simon Carley, “Educational theories you must know: Maslow. St.Emlyn’s,” in St.Emlyn’s, November 4, 2015, https://www.stemlynsblog.org/better-learning/educational-theories-you-must-know-st-emlyns/educational-theories-you-must-know-maslow-st-emlyns/.



Cite this article as: Iain Beardsell, "St Emlyn’s Hierarchy of Wellbeing," in St.Emlyn's, May 16, 2021, https://www.stemlynsblog.org/st-emlyns-hierarchy-of-wellbeing/.

Posted by Iain Beardsell

Dr Iain Beardsell. MBChB (Birm), DipIMC (RCS Ed), FRCEM is section lead for podcasts and Lesson Plans. Editorial Board Member St Emlyn’s blog and podcast. He is a Consultant in Emergency Medicine at University Hospital Southampton and a Consultant in Pre Hospital Emergency Medicine. Iain qualified in 1998 and over the past 20 years has trained and practiced medicine in major teaching hospitals both in the UK and overseas. He has been a consultant at University Hospital Southampton for the past thirteen years, including a three year term as the unit’s Clinical Director. UHS is the main Major Trauma Centre for the South Coast region of England as well as the eighth largest hospital in the UK. Iain is also a highly regarded advisor to television medical dramas, including Casualty and Good Karma Hospital. An acclaimed speaker, Iain has spoken at international conferences in Australia, Ireland, Austria and Germany as well as across the UK. You will find him on twitter as @docib

  1. Thanks Iain, a fantastically well thought through piece.

    I’ll add a couple of things from my own experience/reading which may (though may not) contribute. The first is that that Maslow’s needs are not strictly hierarchical in that you don’t need to fully realise one level in order to reach the next- they can happen in a sort of parallel fashion, though of course to someone without food/water/a toilet then that takes precedence. I think it would come as shock to many outside healthcare the lack of facilities available in a supposedly 24/7 service. Alongside this I’d make comment on the quality of facilities for staff- sometimes these simply send a message that the organisations we work for don’t actually value the staff providing the care. Sometimes coming to work can feel like an exercise in self flagellation, when it simply does not need to be like that.

    The second thing I’ll mention briefly is the wellbeing agenda- I’m lucky enough to be part of the NHS health and wellbeing steering group (I guess due to the Civility Saves Lives work, but I’m honestly not sure) and this has resulted in me spending time getting my head around the area. My reductionist viewpoint is that organisations tend to see it in 3 areas-
    the first is personal mastery, our sense that we should be able to cope with anything that the job chucks at us. We buy into this and become complicit in the belief that we should shoulder the emotional burden of a broken system, listening to Headspace and using Sleepio and becoming frustrated that we cannot just keep going….. Of course this perspective works for organisations because they can shove some of the responsibility for coping onto our shoulders and, to be fair, there is probably some initial improvements that occur through the use of these apps- however the access to improvement they provide is limited, because most of the problems are not with us, they are with the system/organisation/workload.

    The second area I see as having value is the environmental part of the equation, something you cover so well in the article. It can be good to get trusts onboard with this as they will help if they can (in my experience), and opening a new lounge etc provides both a better environment and also a pretty good photo op for the caring execs.

    The third, and least amenable to exec diktat, area of workplace wellbeing is the way we treat each other- the “how we do things around here” part of work. This is consistently shied away from because, frankly, the execs in many places don’t know how to approach this and if they did then their own behaviours would blow any credibility the work might have out the water (probably as a result of them being overwhelmed by work, much luck many of the rest of us in the system). But we can own this at a microculture/departmental level by choosing to describe the way we feel we should be treating each other and compassionately (definitely not aggressively) holding each other to account around it. This is much easier said than done, however there are models that have been proven to work (Gerry Hickson in Vanderbilt has the one I like best) and it is possible to help people to understand the impact their actions have on others. And the evidence is that when we know the impact we have on others then we choose to change if we discover our behaviours are having a negative impact.

    Thanks again for a brilliant article, really made me think.
    Cheers,
    Chris

    Reply

  2. This can also be applied to schools. This helped me clarify why I feel so unhappy working at my current school.

    Thanks you.

    Reply

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