'There is a balance between their fears and their sense of duty'

Ella Rhodes hears from Dr Julie Highfield, whose team are offering critical psychological support to medical teams making life or death decisions while working on the front lines of care around Covid-19.

Dr Julie Highfield is a member of the executive committee for the British Psychological Society's Division of Clinical Psychologists Wales. She's Consultant Clinical Psychologist in Wales’ largest Critical Care Unit in Cardiff.

What do you do?

My day job involves offering a visible psychological model of care to families and patients within the ICU. I’m also the designated lead clinician for staff wellbeing in paediatric and adult critical care units, offering systemic and individual approaches. I’m the Associate Director of the adult unit, which means I sit on the management team and contribute to strategic planning of critical care. 

How has your work in the ICU changed since covid-19 emerged? 

Initially when the virus was in China it was about planning. We were not quite sure what would come, but as the story emerged in Italy we very quickly had to step up our work. For my colleagues that meant a lot of planning around how to create capacity to isolate coronavirus positive patients as we knew the number of beds we needed was far greater than the capacity we have – you can create capacity through other areas pausing their work (such as routine operations). As the Clinical Psychologist supporting my team my job was very much involved in helping them to stay calm and communicate well with each other and their teams. 

Now we are very much in the 'go' or active phase of delivery, where we are providing a service for C-19 positive patients alongside our core business. I am still doing the day job, so to speak; still supporting patients, families and staff. But I’ve had to significantly adapt the way I can do that. My support with C-19 patients is just starting, and I am trying to work out how to support the staff with video links to patients who are less sedated, but we are not quite sure how that will work as yet. We are working out how we might provide family support over telephone links. 

For now I am still seeing staff face-to-face, but with social distancing it's better I move to telephone… plus the office I work from just got closed as it's next to a corridor we need for stores and to create a 'covid positive' area. The one I have been moved to might go the same way in a week or so, or not. It's hard to know. So, I find myself missing my secure base and trying to create a new one rapidly.

The staff are scared about things the public are scared of, trying to wade through all the information that is out there and dealing with the unknown. Plus for some of them they have never had to wear Personal Protective Equipment before, so they cannot quite work out what it might be like – simulation and training can only go so far. There is a balance between their fears and their sense of duty. Most of them are not scared of the virus because they are in the low risk group… they are more scared of passing it on to people who are vulnerable. 

My Heath Board (NHS Trust) have invited me be part of a group to consider the wellbeing of wider staff groups, and I know lots of Psychologists across the UK are feeling in a very similar position. It's hard to slow down all this knee-jerk reaction, but I truly think that systems need psychologically informed action, not psychological intervention, now. Upping access to counselling and psychotherapies is probably not the most prudent use of resources, it's better that they support managers and systems to 'contain' distress, just as much as we are trying to contain the virus. We have to be very careful of encouraging emotional processing of trauma when right now people are not in safe spaces to do this – let's think about principles of psychological first aid instead. Psychological therapies, reflective debriefing spaces will need to be enabled further down the line when people emerge out of the other side and are reflecting back on what they have been through. 

How do you use the psychological evidence base in your work? 

Well, in a standard day job, the evidence base for psychology of the ICU patient is a bit scant! I co-chair a special interest group of psychological professionals in intensive care (PINC-UK) with my colleague and now friend Dorothy Wade, a Health Psychologist in UCLH. To be honest, she’s produced most of the fantastic research in this area. We understand that distress within the ICU is the best predictor of psychological problems post-ICU, and that the largest predictor of distress within ICU is the experience of delirium. So much of my patient work is about trying to help teams manage delirium.

For staff wellbeing, there is much more evidence around what staff need at work, and I am a firm believer in creating systems to sustain wellbeing rather than dancing around the edges with resources. I draw from models such as the Job Demands Resources models, work from Michael West, Amy Edmondson’s work on Psychological Safety, and the recent Tavistock Model for organisations.

As for Covid, well I am lucky to have a bright trainee who is digesting the limited staff working in highly infections diseases literature! There is work from people’s experiences of other outbreaks (MERS, SARS etc) which talks of the themes I have illustrated above.

How is your role likely to evolve in the coming months as we see more cases of the virus? 

I can see a settling period into the 'new normal', where I will be doing the day job from our Bronze Control Room, on hand to support managers who are unable to think straight in the chaos, coordinating low level staff and family support. I’ll have to be careful not to get drawn into the chaos myself and provide that ongoing frontal lobe space for others. I can see me working longer hours, that’s a given. And at some point I suspect I’ll get the virus and need to do all this remotely for two weeks. I will try to remember to breathe! 

When this dies down I’ll be doing a lot of supporting the teams to process what they have been through and work out how we rebuild for a different future. I do believe there will be some positives out of this – we are already learning some of the red tape is not needed and some processes are archaic, and I believe there will be post-traumatic growth. 

Could you tell me how you came to write the staff wellbeing resource with the Intensive Care Society, and what the reaction from staff has been to these tips? 

I had been working on sharing my resources with the Intensive Care Society for some time, and then when this emerged I shared a very simple but it seems effective two-page document – how to set up the system and how to look after yourself. Its been spread so far and wide… I only wrote it last Wednesday (11 March). Since then lots of people have used it as a basis for their response. I walked in to a theatres training session a week later and they had already integrated it into their simulation. People from other countries have been sharing it, and I ended up being interviewed by Channel 4 news. The scale and speed of this is breath-taking and humbling. I am so glad that what I have done has gone some way to helping in all of this. I am now hoping to step up and support a BPS response to this. 

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