Psychologists and military personnel developed the Ground TRUTH After-Action Review tool in March 2020. Drawing on research on what works in after-action reviews, and written by authors with research backgrounds in critical incidents and counselling as well as operational experience, the tool supports adaptive recovery in the intense operational and chronic environment of COVID-19.
Research into debrief approaches has demonstrated that after-action reviews enable users to understand and cope with challenges they face, as well as discuss performance and identify plans for improvement. The Ground TRUTH tool was developed in response to a call from the NHS to help support staff and maximise operational capacity during the COVID-19 pandemic. Here, the authors provide an overview of the tool and its application.
The Ground TRUTH tool aims to:
- Feedback important observations from the ‘ground up’ to shape decision-making.
- Prevent burnout by monitoring fatigue, improving stress awareness, and boosting coping.
- Develop shared understandings by identifying learning fast and improving team morale.
- Be easy, rapid, and efficient, with its deployment as frequent as it was helpful (usually weekly) and brief (sometimes only seven minutes, more often 20). Data had to be easy to manage and easy to interrogate.
There were many successes with the tool deployed across over 50 social care, health, and emergency services, as well as military settings. One notable success was at Alder Hey Children’s Hospital, which had to adapt to caring for adult patients with COVID-19 in response to pandemic pressures.
Working with Dr Sarah Robertson (Clinical Psychologist) in the Staff Advice Liaison Service and Organisational Development, we carefully monitored outcomes.
Feedback from a two-phase implementation found 98% of staff said the tool was helpful, with one-third of staff reporting feeling better after reflection and nobody reported feeling worse. This feedback led to Trust Executives at Alder Hey supporting an organisation-wide implementation with a regular TRUTH slot at their monthly strategic meetings. The Communications Department disseminated targeted and solution-focused in Trust-wide briefings and TRUTH bulletins. This activity led to the Health Service Journal award for Staff Engagement within their ‘flourishing in adversity’ program.
Feedback from a two-phase implementation found 98% of staff said the tool was helpful, with one-third of staff reporting feeling better after reflection and nobody reported feeling worse.
The tool is not intended to identify and monitor mental ill health but is aimed at increasing awareness (of self and others in teams), supporting all staff to proactively monitor and boost coping. These insights improve shared situational awareness among teams while also feeding directly up to team leaders and managers, enabling them to respond more effectively to needs and requirements on the ground.
The five stages of TRUTH
Talk and log the issue – ‘What was difficult?’ (negative) and ‘what worked well?’ (positive).
Review management of the issue, preferred outcomes, and ‘making tomorrow a better day’ for the organisation.
Understand what can be learnt from the event – this is goal-directed and future-leaning, asking why this happened and what we can learn.
Tell others and the organisation what is needed to improve responses.
Heal and move forward – focusing on reducing stress, improving morale, health and wellbeing.
We adopted a self-initiated approach utilising active listening, authenticity, and compassion. With regards to the therapeutic principles enshrined within the tool, we were:
- Non-directive: the tool is user-led and provides prompts to encourage reflection.
- User-centred: the user is always the best person to resolve issues; the tool enables user-centred learning.
- Positive: the user builds resilience through self-empowerment.
Data is hosted on an online platform that can be used by individuals alone, in pairs, or in groups. Data can be extracted to create outputs for teams. Outputs include summaries of categorical data related to issues, successes, goals, learning, and average morale and coping. Outputs can be shared with TRUTH leads, line managers, and strategic leads.
Leads can utilise the information to enhance existing infrastructure, such as in team meetings, supervision, debriefs, and reflective spaces, accelerating the ability to get teams to gain a fuller shared picture (Mathieu et al., 2000). Reports are shared via email and in posters in clinical areas. Decision-makers respond with key actions in the form of a TRUTH bulletin. Themes are used to shape the offer of staff support responsively and proactively.
Because of the specific success at Alder Hey and increasing demand across the health sector, we are now working with Alder Hey to form a TRUTH team to produce guidance, manuals, and materials that will feed into a comprehensive toolbox. We are also supporting launches in similar healthcare settings, as well as military and disaster-response organisations.
The key to the tool’s success was recognising that during fast-moving, high-stakes, and chronic critical incidents, psychological support needs to be rapid, efficient, and responsive to the operating environment. There is no luxury of time to support staff, nor the need nor utility (during ‘the storm’ itself) for lengthy unpicking and discussion of stress and trauma.
To support staff in such high-stakes environments and enduring times of stress, we need to recognise tempo, bandwidth, and the importance of listening. Working within the staff’s ‘window of tolerance’ to identify and remove obstacles can support adaptive recovery at an individual and organisational level, improving people management, human performance, and reduced sickness.
- Alison et al. (2020). Project ARES:Resources to support front-line workers responding to COVID-19. University of Liverpool. https://www.liverpool.ac.uk/project-ares/
- Alison, L., Alison, E. (2020). Rapport: The Four Ways to Read People. United Kingdom: Penguin Random House.
- NHS (2020) Interim People Plan 2020-2021. Available online at https://www.england.nhs.uk/ournhspeople/online-version/
- The Lancet (2020). COVID-19: protecting health-care workers. Lancet (London, England), 395(10228), 922. https://doi.org/10.1016/S0140-6736(20)30644-9
- Greenberg N. Nightingale Mental Health Team Standard Operating Procedure. Version 2.3. Owner of SOP: Professor Neil Greenberg. Last update: 06/04/2020. Staff Morale and Well-Being During the COVID-19 Pandemic | Psychiatrist.com
- Walton, M., Murray, E., & Christian, M. D. (2020). Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic. European Heart Journal: Acute Cardiovascular Care, 9(3), 241–247. https://doi.org/10.1177/2048872620922795
- Mathieu, J. E., Heffner, T. S., Goodwin, G. F., Salas, E., & Cannon-Bowers, J. A. (2000). The influence of shared mental models on team process and performance. Journal of Applied Psychology, 85(2), 273–283. https://doi.org/10.1037/0021-9010.85.2.273
- For more information and the tool: PROJECT ARES | Ground Truth (ground-truth.co.uk)
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