A focus on... psychologists providing support in intensive care units and similar medical settings - Keith Miller
Managing the stress faced by staff within the NHS has never been more important. It is essential to meet the psychological support needs of staff if the quality and quantity of clinical care is to be maintained.
The work described in this bulletin demonstrates clearly that clinical psychology can offer a vital contribution in this area, especially if effective professional leaders are working at senior levels in NHS organisations. In the September edition of the DCP Covid bulletin, we examined the role of clinical psychologists as leaders in the NHS. The initiatives reported demonstrated that if effective and credible clinical psychology leadership was in place, organisation-wide practices could be introduced which brought psychological perspectives to bear on the epidemic in ways that were enthusiastically adopted at board level.
This process is evident in two of the initiatives described in this bulletin where clinical psychologists are operating at a national level (Lynne Taylor in Scotland) or board level (Harriet Conniff). We also have a valuable report from the situation, which is quite common, where a psychologist is providing support to an intensive care unit without explicit organisational support (Rachel Clarke).
Not all clinical psychology services have an effective head of profession. This role can be very challenging (given the clinical dominance of medicine and nursing in NHS settings).
Two conditions need to be in place for it to be effective:
Without this being in place, the head of psychology role has a severely reduced, potentially minimal impact on the development of new services to respond to the pandemic.
External professional involvement in the appointment process for heads of service
Unless the newly re-launched national assessor scheme becomes a feature of every appointment to head of psychology posts (as is the case in Scotland), we will not make consistent advances in this area.
Meeting these conditions will enable significant advances, both in clinical psychology effectiveness and responses to the pandemic.
Supporting staff within intensive care units during the pandemic - Dr Julie Highfield, Consultant Clinical Psychology and National Wellbeing Director for the Intensive Care Society
I have worked as a clinical psychologist in medical settings for many years, but for the last six years I have been based in adult and paediatric intensive care with a role originally set up to offer a visible psychological care model to patients, their families and the staff. In addition, I was part of the unit’s directorate management team on a temporary contract one day a week. In the background, I offered some consultation to the Intensive Care Society, the charity that represents all clinicians in UK intensive care.
As for so many of us, 2020 changed my work. The number of staff referrals increased exponentially as ICU staff were exposed to high stress, increased pressures, and stretched staffing ratios. The Intensive Care Society offered me a 0.4WTE secondment from June 2020 to lead on their three-year wellbeing project.
The core vision of the Intensive Care Society Wellbeing Project is that sustaining the wellbeing of ICU staff means that they can provide a better service for patients, making safer decisions and fewer mistakes. This is not just about how individuals manage the stress of the job; it is about how the job is designed (including how valued staff feel at work, autonomy and sense of control), the way the unit is managed and the team is led, and the support of peers.
An important consideration for clinical psychologists in this position is that much of our training lends itself to us providing direct psychological care, space for reflection, and space for recovery. This is, for the most part, within the interventions required for staff who are struggling at work or who are dealing with ongoing mental health issues.
However, for a full wellbeing at work model the system needs to create the core conditions for staff to thrive at work. This largely comes from leadership and culture. It goes without saying that the ongoing cause of acute stress comes from high patient numbers and the stretching of staffing rations- staff tell me that they just don’t feel safe.
The ICS wellbeing offer is to provide free psychological resources on a national level aimed at both managing staff struggling at work as well as investing in the core conditions to thrive.
These are as follows:
- Direct provision of 1-1 psychological support to any ICU member of staff
- Support to develop local ICU psychology posts through benchmarking and business cases
- A rolling programme of psycho-education including managers mental health awareness, team care, and self care.
- A peer support training and framework
- Free written resources, webinars and podcasts
- Guidance for managers to provide the core conditions for staff to thrive at work
- Leadership support and development
- Research: working with partners to develop novel psychological interventions and to monitor the mental health of the ICU workforce
All resources can be accessed on the ICS website.
Psychological support for staff within an intensive care unit - Keith Miller talks to Dr Rachel Clarke
During the early weeks of this year, TV news has frequently presented harrowing images of over-stretched ICUs with staff at the limit of their capacity and endurance trying to offer care to large numbers of patients in life-threatening (often end of life) situations. This coverage reflects the reality of a critical healthcare situation and makes the issue of how psychologists can intervene effectively in this setting vitally important.
Psychological support has been offered to ICU staff for a number of years prior to the pandemic. It is important to acknowledge how demanding the ICU is as a clinical setting within which to intervene psychologically. Some years prior to the pandemic, one of the pioneers of psychological work in this area, Dorothy Wade, noted that:
"The role of a psychologist in an ICU is highly complex one in a sensitive, complex, medical environment. To provide a coordinated service across the critical care department, ideally a consultant-level health, clinical or counselling psychologist should be employed to ensure the necessary seniority, experience and expertise. Additional junior psychology staff could be employed to support the senior psychologist, according to numbers of beds, specialities or units within the department. With such a multi-faceted role, and high-level need, burnout is a risk for the senior psychologist, similarly to other critical care staff, if the psychology service is not properly structured and staffed".
Dr Rachel Clarke has worked for the past three years in the ICU at Derriford Hospital in Plymouth. Rachel qualified as a clinical psychologist some ten years ago and she talked about her role as a lone mid-career psychologist in this setting. Rachel is not employed at the consultant psychologist level described above. Nevertheless, she has carved out a valued role within the ICU, using local knowledge and carrying out literature reviews and internet searches to develop a patient- and staff-centred approach.
The most important professional links she has formed have been with the psychologists in Intensive Care UK (PINC-UK). This group is co-chaired up by Julie Highfield and Dorothy Wade. Julie Highfield is now the national well-being lead for the Intensive Care Society and has produced a number of extremely useful resources detailing various aspects of staff support in this setting.
Adapting the above body of work to her particular clinical setting, the main types of interventions Rachel has employed with the unit’s staff are as follows:
This is flagged up through a weekly email sent to staff on the unit covering topics such as psychological first aid, resilience and wellbeing strategies. The focus is on working alongside staff to enable them to notice being human in such difficult situations.
Individual support - informal and brief therapeutic interventions
Through a visible presence on the unit, Rachel has been available for staff to talk informally or, on occasion, engage in more formal brief therapy interventions including EMDR.
Group-based staff support
Rachel has run a 20 minute care space for groups of staff. The purpose is to provide a space for self-care through facilitated connection and support.
These interventions offer the potential to offer psychological support to colleagues experiencing previously unknown levels of demand. The aim is also to support the clinical effectiveness of the unit by enabling staff to function in extremely stressful circumstances. As in most healthcare settings, informal support systems on the ward have been disrupted by the Covid outbreak.
Outside the unit, opportunities for informal socialising and support have been curtailed because of social distancing and lack of places to meet. Inside the unit, the use of PPE severely interferes with day-to-day supportive interactions among staff. Furthermore, pressure on beds has necessitated senior nursing staff having their offices used for patient care meaning that their ability to be a containing presence for more junior nursing staff on the unit is curtailed.
Rachel drew attention to the lack of nationally agreed service models or quality practice standards for psychologists working in ICU. The Intensive Care Society published the most recent Guidelines for the Provision of Intensive Care Services in June 2019.This document (which runs to 251 pages) includes three pages covering staff support and three pages examining the role of psychologists. While this is an important step forward, more detail is needed about deployment of psychologists in this setting.
It is clear that psychologists in Rachel’s situation would greatly benefit from agreed DCP/BPS guidance about psychologically-based service models for clinical psychology deployment in ICU, along with quality practice standards and an evidence base around interventions for staff, patients and families.
We will be following up on these issues in future Covid bulletins with the aim of enabling other psychologists working in this key clinical setting to work from an agreed set of work priorities and quality standards.
Psychological support for staff across a large acute NHS trust during the pandemic - Keith Miller speaks to Dr Harriet Conniff
Dr Harriet Conniff is lead for staff support from a psychological perspective at Evelina Children’s hospital in London. The hospital is part of Guy’s and St Thomas’ Trust (GSTT). This is a very large acute healthcare organisation with more than 25,000 staff, with 3,500 staff in the Evelina Hospital. She spoke about how her role has evolved since she came into post in 2018.
Her job initially involved leading on the development of a staff support system across this paediatric hospital and, working systemically, she gained support and input at executive level within the Evelina, particularly from the medical director and director of service improvement as well as working alongside paediatricians, heads of nursing and the medical mediation service that works at the Evelina. She also worked directly with staff teams regularly on intensive care, offering reflective practice groups and psychological debriefing sessions to staff on the unit.
Her role pre-Covid involved three major elements:
- Developing a 3-stage debrief pathway for use across Evelina London. This comprised a ‘hot debrief’ immediately after any serious incident, a 48- hour follow up and a scheduled psychological debrief if needed.
- Carrying out a co-ordinating, supervising and consulting role in respect of the other clinical psychologists who were involved in staff support.
- Pooling all the trust’s and Evelina’s wellbeing resources into a ‘one-stop shop’ where staff could easily access support and information as required.
GSTT was one of the first trusts to care for Covid patients - the pandemic began to directly impact the organisation on 6 February 2020. Harriet was able to expand her role and increase psychology’s influence largely as a result of two key elements. Firstly, her approach was already embedded in the systems of the organisation and, secondly, the appointment of consultant clinical psychologist, Dr Neil Rees, in the role of trust lead for staff health and wellbeing in occupational health.
Harriet and Neil worked together as senior colleagues enabling higher level strategic interventions within the organisation particularly involving applying psychological thinking to communication with staff, redeployment and Covid resource development. Links have also been strengthened between embedded psychologists and wellbeing psychologists within the organisational development and occupational health departments, drawing together various programmes that support staff.
A constant and crucial feature has been trust executive involvement as the need for staff support increased over the course of the pandemic, and both Neil and Harriet sit on the wellbeing subgroup of silver command enabling a dialogue about wellbeing at executive level. Wellbeing zones and rest and recharge zones staffed by wellbeing champions have been configured and conversations about wellbeing are now included in staff development reviews throughout the organisation.
A successful funding bid to GSTT charity has resulted in the creation of a further nine staff support posts filled by clinical psychologists (including two working with Harriet) which enables the initiatives described above to be further rolled out across the organisation.
There is extreme variability across the NHS in terms of the extent to which our profession is involved in staff support at all, especially the organisation-wide systemic approach described above. As such, we have much to learn from the success of this approach, particularly in engaging with the most senior staff in the organisation and adopting a systemic perspective.
A focus on... staff support systems being developed across across the UK - Lynne Taylor, Psychology Adviser to the Scottish government, speaks to Keith Miller
Dr Lynne Taylor has just been appointed as the psychology adviser to the Scottish Government. This represents a significant milestone, both for Lynne and the profession of clinical psychology.
12 months ago, as the COVID pandemic began, Lynne was working in the Grampian area of Scotland where she was director of psychology. Her work there demonstrated how clinical psychologists can work at health board level, enabling health staff and members of the public to manage the psychological stress and trauma caused by the pandemic.
In March 2020, she and a colleague, Dr James Anderson, set up the Grampian Psychology Resilience Hub to support people affected by Covid-19. Its inception and development was rapid, mainly because they had been working for some months on developing psychological support systems that could be deployed at a population level to manage the psychological consequences of a major disaster.
This earlier work was at the request of the civil contingencies team in Grampian and was based on the psychological services that were set up after the Manchester Arena bombing and the choice and partnership (CAPA) model for CAMHS.
The resilience hub consists of a stepped and matched care model with initial psychological screening which allows people to be classified at low, medium and high levels of distress. The system is open to any staff member, and the public of any age. It has a single point of access and provides an integrated care model with no ‘wrong door’ of entry.
Following assessment, people using the service are matched to clinician skill level based on their assessed needs. They receive evidence-based psychological first aid which consists of up to three sessions of individual therapy sessions. During this brief intervention, a formulation is produced, advice is given and self help techniques discussed.
If further input is required, service users can be referred on to secondary care services but most people are helped by this early care and prevention service. The model has adaptability to be used in other areas to provide population level evidence based psychological support.
Lynne’s influential new post as the Scottish government’s psychology adviser affords an opportunity for clinical psychology to have a positive impact at a national level. Lynne will be part of a multi-disciplinary national professional advisory group which includes a mental health nursing adviser, principal medical officer, professional adviser for mental health, and soon to be appointed AHP lead.
This team can provide specialist advice to Scottish Government civil servants and ministers as required. Her early priorities are advising on future planning and renewal plans due to impact of Covid, working with colleagues on priorities for allocated monies for mental health, psychological support for Long Covid, advising about the needs of children and young people and advising on population-wide initiatives around psychological wellbeing.
Lynne’s role is a conduit between the Heads of Psychology Scotland (HOPS) group for lead psychologists in Scotland on the one hand and ministers, and civil servants on the other. The HOPS group has some 20 members representing every health board, the heads of the Scottish clinical psychology training courses, and the NHS Education for Scotland lead for Psychology. Entry to these senior clinical posts is strongly supported by a well-organised national assessor scheme ensuring quality control at the most senior level in the profession.
Lynne argues strongly that there is no better time than now for the profession of clinical psychology to demonstrate its positive impact on several key national concerns in the pandemic. She says:
"It is a time for leaders in the profession to be brave and bold and act on opportunities”.
NHS Wales - Dr Adrian Neal, Consultant Clinical Psychologist and Head of Employee Wellbeing
NHS Wales has, on the whole, taken a two-pronged approach to supporting its 90,000 staff during the pandemic, and the past 12 months has seen a sizable increase the resources available at both national and local level.
What’s more, social care staff have now also been included in the wider national wellbeing offer. I will try and give you a broad over view of what support is currently available for NHS and Social Care staff in Wales, more specific detail can be found in this document.
NHS Wales has not imposed an expectation of a standardised approach to employee wellbeing on its seven health boards and three trusts. This is important, as there is significant pre-pandemic complexity in each organisation including variations in need, size/scale of workforce, organisational structures, cultures, geography and wellbeing related resources. The pandemic has had a different impact on each NHS Wales organisation, given they are mostly determined by physical and political geography.
That said, the pandemic has, I believe, led to all 10 organisations strengthening their local commitment to, and support of, employee wellbeing. Much of this work has been led by clinical psychologists who are either leading or deeply embedded within established local NHS psychological wellbeing and/or occupational health services.
Indeed, to the best of my knowledge, NHS Wales has some of the longestestablished and pioneering psychology-led wellbeing services in the UK. This is something I think we in Wales need to be proud of. The pandemic has seen some of these services receive significant additional financial support to be able to extend their capacity and adapt to care for the carers of NHS Wales.
In addition to the more specialised local wellbeing and occupational health services and resources, the pandemic has also seen increased collaboration and coordination and a national level. Much of this collaboration has been hosted by the relatively newly formed arm of Welsh Government, Health Education and Innovation Wales (HEIW), which has served to identify and promote excellence in wellbeing practice and collaboratively develop shared national resources.
HEIW had started to perform this role before the pandemic, so it naturally continued to do so. Clinical psychology has played an important role in shaping HEIW’s (thus NHS Wales') understanding of both wellbeing and the impact of the pandemic, as well as leading on the development of specific Covid-19 resources including a national wellbeing strategy, online self-help guides, and a quality control tool to assess the many wellbeing related offers that emerged during the first wave. HEIW has commissioned a number of national psychological support services, which includes a provision for social care staff.
As we reach the tail end of the second wave of the pandemic, and the focus of NHS Wales’ leaders moves from surviving to sustaining their workforces, clinical psychologists can offer an invaluable contribution, through their leadership, expertise and their ability to understand the psychosocial needs of our colleagues and their places of work. In Wales I think we are well positioned to be able to make this contribution.
Northern Ireland - Dr Dympna Browne, Consultant Clinical Psychologist for Belfast Health & Social Care Trust
Undoubtedly similar to other nations, the Northern Irish psychology workforce has had to rapidly pull together its resources in order to support health and social care staff in their efforts to save lives during this time of global crisis.
Leadership has come from the Northern Irish Regional Workforce Wellbeing Group, chaired by Dr Sarah Meekin, head of psychological services for Belfast Health and Social Services Trust. This group sets the regional direction in the coordination and delivery of advice, support and interventions in relation to the psychological impact of Covid-19 on the health and social care workforce.
It meets fortnightly, with representation from the Department of Health, each of the HSC Trusts, the Public Health Agency, Health and Social Care Board, the HSC Leadership Centre, trade unions, the Northern Ireland Ambulance Service and Fire & Rescue Service, primary care, the independent care sector and community pharmacy services. The group reports to the director of workforce policy at the Department of Health.
In order to guide leaders in responding positively to the demands placed on staff during the pandemic, the regional workforce group produced a framework entitled ‘Supporting the Wellbeing Needs of our HSC staff during Covid-19: A Framework for Leaders and Managers’, which was launched by minister for health Robin Swann in April 2020 and was informed by the ‘Psychological Needs of Healthcare Staff as a result of the Coronavirus Pandemic’, guidance produced by the BPS.
It outlines the key principles of responding well for sustained staff wellbeing, the anticipated psychological responses during phases of the pandemic and the principles for wellbeing support across these phases. In line with this framework, psychologists in each of the five health and social care trusts have developed a range of resources including, psychological support helplines, online mindfulness sessions, drop-in clinics and team reflective practice sessions such as caring spaces and team time, and team workshops reflecting on compassionate approaches to self-care and care of others.
Psychological therapies for staff requiring more intensive support are also available, either through existing occupational health psychology resource, or via re-deployed psychological staff from other areas. Ensuring resources are accessible can be challenging and a number of trusts are using pagetiger technology to try and make sure staff have access. Some trusts have also made information available in hard copies, as there is evidence of digital fatigue.
Given the unprecedented nature of the pandemic, we are keen to contribute to psychological research. The Impact Research Centre in Northern Ireland, led by Dr Ciaran Shannon, consultant clinical psychologist, was awarded £68,274 under the HSC R&D Division's Covid-19 funding to investigate the impact of Covid-19 on staff wellbeing and the effectiveness of staff wellbeing interventions.
A total of 3,834 HSC staff across the region have taken part in this study to date and the results of Survey 1 which took place during the second surge of the pandemic have been published. The survey will be repeated a further three times in order to measure the psychological impact of the pandemic on staff wellbeing and in order to evidence the effectiveness of interventions offered to staff during the key phases of the pandemic.
Covid-19 has had and will continue to have a significant impact on the mental health and wellbeing of HSCNI staff as they experience a range of stressors including traumatic exposure, moral distress, bereavement and burnout. In the foreseeable future there will be a continued need for psychology services to lead on a stepped care model to provide an appropriate level of intervention to staff teams and individuals.
This pandemic has brought into sharp focus the inequity between trusts in psychology provision into occupational health departments, and consequently each trust is urgently seeking funding to expand psychological services available to staff.
England - Angela Kennedy, Clinical Director for the North East and North Cumbria Staff Wellbeing Hub
NHS-England gave funding to the North East and North Cumbria to set up and deliver an infrastructure for staff wellbeing. The staff wellbeing hub was been set up by the North East and North Cumbria Integrated Care System, using secondments to rapidly deploy staff with the range of skills needed.
Its aim is to support our region’s health and care staff to access what they need to stay mentally well throughout the Covid-19 pandemic. The hub doesn’t replace other services. Instead, the hub helps staff to navigate the offers and find what is best for them in a confidential and expert way.
The trauma-informed principles and values on which our hub was developed are:
- Relationships are the basis of recovery: Staff want and deserve real contact with experienced mental health experts at the outset.
- Whole-system thinking: to work productively across agencies to create easy and timely access for staff and plug any gaps.
- Normalisation and strengths-based approach: non-pathologising language and preventative offers for individuals and teams.
- Empowerment: a range of quality offers to choose from, including specialist therapy and confidential self-referral.
- Addressing complexity: dealing with the unique and multi-layered nature of staff mental health.
The team has a number of core tasks in the set-up of the hub:
- Co-produce the hub’s aims and pathways and gel relationally as a team
- Set up systems to collate information and function as a team across various providers
- Collate the various offers and assets in a meaningful way and find ways to communicate this
- Organise a helpline for staff with clinicians to support and assess them
- Develop pathways for access
- Engage partners and staff with active outreach and support visits on hospital sites
- Develop and launch a self-monitoring diary for staff
- Work with Health Education England to produce experiential learning resources
- Work with agencies to commission services to fill gaps, e.g. leadership coaching, moral injury interventions, Balint groups, Bodywork
- Develop webpages including a ‘wellbeing toolkit’, and a communication plan
- Develop bespoke needs-led outcome monitoring and evaluation of the hub
The team is looking to support staff with a range of difficulties. Staff may be in immediate distress and services need to think how they can operationally minimise that for staff. Supporting leaders will be critical. Physical wellbeing may be impacted. Staff may develop Long Covid symptoms themselves, lose fitness because of home working or have somatic symptoms of distress.
They may have bereavements themselves or have fears for their own health or that of their family. Staff may be at risk of burnout or PTSD. Moral injury is coming up as a powerful theme which needs to be addressed early. We found many ideas through a large scale survey for moderating this. This included kindness and support to emotionally regulate managers, regular wellbeing checkins with trusted senior staff, finding ways of creating fairness, choice, and transparency in work tasks, and enforcing rules safely.
The clinical hub team members have been allocated to frontline services as link workers so all services have a familiar face they can liaise with directly. This covers older people, primary care, acute trusts, ambulance staff, the helpline, and locally devolved and locally bespoke delivery of staff support.
Issues and way forward
There have been some challenges to overcome in the set-up of the hub.
The first is the pace and timescale of delivery. This has only been achieved through huge efforts from the ICS programme management and the motivation of the hub team to create something of value for their colleagues.
The second issue is the challenge of working across a wide area across multiple partners, all with their own cultures and differences. Finding ways to safely set something up has forged some learning for the new legal status of the ICS structures that will come into place next year.
Finally, our local intelligence suggested that the need and hope was that this hub may need to be slightly different from NHS England’s expectations.
So far, we have had support in forging a support offer based on our core values and the local need. The motivation for adapting to staff changing need is there.
Collective healing will be required as our NHS community recovers and grows from the trauma of the pandemic, and we hope to be part of that over time.