I am a Principal Clinical Psychologist working in an acute hospital in London. I work within the Paediatric Intensive Care Unit (PICU), as well as supervising members of the team, supervising trainees doing research and working on a number of other projects.

In my day-to-day role on PICU I meet families, often at the lowest point in their lives with a very seriously ill child who may die. I generally use Compassion Focused Therapy as my guiding model, supporting parents through an incredibly difficult experience. When I first meet parents, my initial questions are always to ask whether they have eaten or drunk that day, and whether they got any sleep the previous night. These basic building blocks of compassionate care feel important and a way of making it clear to families that I care very much about them and their experience, rather than having my own therapeutic goal or aim in mind. Always in this work we must sit with enormous uncertainty, not knowing what will happen next and aware that things can change very suddenly, or not change for what feels like an eternity. When children do die our work often involves helping parents to manage the process, including saying goodbye to their child where there is time for this, sharing the news with siblings, and finding existing sources of support for them (often wider family or friends) as they return home without their child. I mention this work because all of this is highly relevant to the work I now find myself doing in a hospital treating patients with Covid-19.

We were talking about Covid-19 weeks before it had a real impact on my work, and in fact I saw the impact in my personal life first, with a creeping sense of anxiety and dread, and then subsequently the introduction of social distancing and the announcement that schools would close as life began to change dramatically for us all. The day the schools closed I developed a painful and wheezy chest, and thus could not attend work for 7 days. This was when life changed dramatically for us all. I continued to work remotely during this time.

As a team, when social distancing guidance was announced, we started off working remotely, something which gave me a fair amount of moral distress. I am completely behind the need to reduce staff in the hospital as we try to contain the spread of the virus, and like the whole country is being asked to stay at home, I see not spreading this virus as my moral duty. But I also feel that I need to be there at a time when my unit need support the most. We’ve tried to be responsive to changing need and as soon as a request came in for one-to-one support, we changed our working practice and are in the department on a rota now, and meeting with staff directly but at a distance.

In my work I continue to support families who have children on the PICU, but this work has declined sharply because many of our patients have been moved to increase capacity for adult patients. I have also been recruited to a trust-wide staff support and wellbeing working group, which is developing support packages and resources for all our staff. This group is made up of Clinical Psychologists, a Health Psychologist, counsellors (in our staff-support service) and doctors. We aim to deliver staff support to the 4000-5000 staff working in our trust. This is no small task. The literature base suggests that in the acute phase staff need practical support like food, protected break times and good communication. During a major incident like a bombing the acute phase may be over within hours and certainly within 2 weeks, but we find ourselves in a prolonged acute phase, as bed capacity increases and more patients are admitted, and more sadly die. The literature about the acute phase matches well with my experience of parents in critical care, with whom I have so many conversations about whether they have eaten and almost none about whether they are depressed or not.

I’ve been very keen that our group sticks with the evidence base, and refers to the work of Dr Julie Highfield (2020) from The ICU society and other evidence-based documents (e.g. Billings et al., 2020) in order to consider what we can deliver. Over time I have seen a movement from a desire to rush in and help, to recognising the current needs of staff, and an awareness that the kinds of intervention which are most helpful are different to what we might be used to offering. I think one of the key tasks for our team is to be able to provide thoughtful and safe spaces for reflective practice to staff who may be highly stressed, and therefore less able to use their frontal cortexes beyond the complex task of caring for patients. I also think we have a big role to play in using techniques like ‘Psychological First Aid’ and other evidence from social psychology which focuses on normalisation of difficult feelings, connecting people with their existing social support and fostering togetherness (e.g. Drury et al, 2009). I’ve highlighted these themes to managers, the communications team for the trust and a variety of colleagues who I think are best placed to disseminate these messages to teams. Our trust has been good at providing clear communication and emphasising the role that teamwork plays in managing the challenges we face.

One of the papers I’ve published about the recovery following PICU admission (Atkins, John & Colville, 2020) talks a great deal about the idea of coming to terms with a ‘new normal’. I now see people using this term to describe their new lives in lockdown, the way the NHS is being revered and the hero worship of keyworkers. When I used this term I was talking about life after the very difficult event. What we discovered through our research is that following a PICU admission life really is not the same ever again, and thus families need to process what has happened to them, develop a narrative, and subsequently arrive at a ‘new normal’ which they can live with. I think the same will be true of the events we are living through. We are in the trauma at the moment – coping as best we can, dealing with the difficult feelings and finding a way to live. But when the worst of this has passed there will be significant challenges to process and come to terms with how life is on the other side.

In my normal role I also support families post-discharge from PICU, as we know that after discharge there is a high risk of post-traumatic stress symptoms and it takes families (parents and children and the wider family) a great deal of time to process their experiences. Some will need bespoke trauma therapy and in our department we offer Eye Movement Desensitization and Reprocessing (EMDR), Narrative Exposure Therapy (NET) and Trauma-focused CBT to such families. I think there will be a need for this work once we move from the acute phase to the ‘aftermath’, and we will need to think carefully about how we support staff for some time to come.

Dr Ellie Atkins is Principal Clinical Psychologist in the Paediatric Psychology Service in St George’s NHS Foundation Trust

References

Atkins, E., John, M. & Colville, G. (2020). Families’ experience of life in the year after a child’s critical illness: Navigating the road to a ‘new normal’. J Pediatr Intensive Care. DOI: 10.1055/s-0040-1705132.

Billings, J. et al (2020). Guidance for planners of the psychological response to stress experienced by hospital staff associated with Covid: Early interventions. Covid Trauma response working group rapid guidance. Version 1 (27^th March 2020).

Drury J, Carter H, Cocking C, Ntontis E, Tekin Guven S and Amlôt R (June 2019) Facilitating Collective Psychosocial Resilience in the Public in Emergencies: Twelve Recommendations Based on the Social Identity Approach. Front. Public Health 7:141.doi: 10.3389/fpubh.2019.00141

Highfield, J. (2020). Advice for Sustaining staff wellbeing in critical care during and beyond Covid-19. Published by the Intensive Care society at https://www.ics.ac.uk/ICS/Education/Wellbeing/ICS/Wellbeing.aspx?hkey=92348f51-a875-4d87-8ae4-245707878a5c accessed on 20/3/20.