Should all PICU staff receive mandatory counselling?
Gillian Colville
Consultant Clinical Psychologist
St George’s Hospital, London
Outline
• Question
• Evidence
• Context: New sources of strain
• Types of distress
• Levels of intervention : individual, unit, organisation
• Individual strategies
• Conclusions
Question
Should all PICU staff receivemandatory counselling?
More questions
• How serious is the problem?
• How can we measure it?
• What is the nature of their distress?
• What are the root causes of this distress?
• Is it getting worse?
• What can we do about it?
More questions
• How serious is the problem?
• How can we measure it?
• What is the nature of their distress?
• What are the root causes of this distress?
• Is it getting worse?
• What can we do about it?
Evidence of distress
• Burnout rising faster in doctors relative to general general population between 2011 and 2014 (Shanafelt et al 2015)
Shanafelt et al. Mayo Clin Proc 2015;90(12):1600-1613
Evidence of distress
• Burnout rising faster in doctors relative to general general population between 2011 and 2014 (Shanafelt et al 2015)
• Critical Care specialty reports most burnout (Medscape annual survey 2018)
Burnout Report 2018 n>15,000 Physicians
Evidence of distress
• Burnout rising faster in doctors relative to general general population between 2011 and 2014 (Shanafelt et al 2015)
• Critical Care specialty reports most burnout (Medscape annual survey 2018)
• ICU staff report more PTSD symptoms (Mealer et al )
• Moral distress higher in intensive care staff (Whitehead et al)
• ? Moral distress higher in PICU (Larson et al 2017)
Context: new sources of strain
• Increased levels in survival with significant morbidity
• Increased expectations of public and organisations
• Downsides of Family Centred Care
• Terrorism
• Criticism/vilification in media and social media
• Admin burden
“Our data compared with the historical data
suggests that pediatric critical care may have
exchanged mortality for morbidity over the
last several decades.”
Pollack et al 2014
Context: new sources of strain
• Increased levels in survival with significant morbidity
• Increased expectations of public and organisations
• Downsides of Family Centred Care
• Terrorism
• Criticism/vilification in media and social media
• Admin burden
Outstanding care
Context: new sources of strain
• Increased levels in survival with significant morbidity
• Increased expectations of public and organisations
• Downsides of Family Centred Care
• Terrorism
• Criticism/vilification in media and social media
• Admin burden
Coats H et al. Am J Crit Care 2018;27(1): 52-8
Context: new sources of strain
• Increased levels in survival with significant morbidity
• Increased expectations of public and organisations
• Downsides of Family Centred Care
• Terrorism
• Criticism/vilification in media and social media
• Admin burden
2017….
Importance of social betrayal in the development of traumatic stress
Low social betrayal *High social betrayal*
Low life threat Child sexual abuse
*High life threat* Accident, serious illness Murder, terrorism
Context: new sources of strain
• Increased levels in survival with significant morbidity
• Increased expectations of public and organisations
• Downsides of Family Centred Care
• Terrorism
• Criticism/vilification in media and social media
• Admin burden
Context: new sources of strain
• Increased levels in survival with significant morbidity
• Increased expectations of public and organisations
• Downsides of Family Centred Care
• Terrorism
• Criticism/vilification in media and social media
• Admin burden
Evidence for interventionsWest et al 2016; Pangioti et al 2016
• Inconsistent definitions of burnout across studies
• Limited follow up data
• Some evidence of added benefit of combined/organisational approach over individual only
• Also, resilience training, mindfulness, reflective practice, moral distress consultation services, trauma-informed service educational packages, evidence base for individual trauma focussed CBT and EMDR (NICE 2005)
Initiatives
• US Critical Care Collaboration Call for Action 2016
• US NEJM Catalyst Project
• Canadian programme re Moral Distress University of Alberta
• First Chief Wellness Officer at Stanford – Tait Shanafelt
Initiatives
• US Critical Care Collaboration Call for Action 2016
• US NEJM Catalyst Project
• Canadian programme re Moral Distress University of Alberta
• First Chief Wellness Officer at Stanford – Tait Shanafelt
Initiatives
• US Critical Care Collaboration Call for Action 2016
• US NEJM Catalyst Project
• Canadian programme re Moral Distress University of Alberta
• First Chief Wellness Officer at Stanford – Tait Shanafelt
Initiatives• US Critical Care Collaboration Call for Action 2016
• US NEJM Catalyst Project
• Canadian programme re Moral Distress University of Alberta
• First Chief Wellness Officer at Stanford – Tait Shanafelt
• UK ‘Thriving at work’ report by Stevenson and Farmer 2017
• UK PICS survey 2018
• UK Collaboration ICS/BACCN/FICM
‘Thriving at Work’ 2017
Initiatives• US Critical Care Collaboration Call for Action 2016
• US NEJM Catalyst Project
• Canadian programme re Moral Distress University of Alberta
• First Chief Wellness Officer at Stanford – Tait Shanafelt
• UK ‘Thriving at work’ report by Stevenson and Farmer 2017
• UK PICS survey 2018
• UK Collaboration ICS/BACCN/FICM
Initiatives• US Critical Care Collaboration Call for Action 2016
• US NEJM Catalyst Project
• Canadian programme re Moral Distress University of Alberta
• First Chief Wellness Officer at Stanford – Tait Shanafelt
• UK ‘Thriving at work’ report by Stevenson and Farmer 2017
• UK PICS survey 2018
• UK Collaboration ICS/BACCN/FICM
What should we measure ?
•Burnout
•Moral distress
•Post-traumatic stress
Burnout
•Maslach Burnout Inventory (22 items on emotional exhaustion, depersonalisation, low personal accomplishment)
•aMBI (9-item version)
•ProQOL (burnout, compassion fatique, job satisfaction
Intensive Care Medicine 2018;44: 681-689
Burnout- Individual level- Team level- Organisation level
Burnout- Individual level- Team level- Organisation level
“When we work on resilience, we’re just trying to create a ‘super canary’… But it’s the toxic gas that’s killing the canaries that we really have to be focused on.”
De Chant NEJM Catalyst 2018
Burnout- Individual level- Team level- Organisation level
Burnout- Individual level- Team level- Organisation level
HALT Campaign
49
Moral distress
•Moral Distress Scale - R (Hamric et al 2012)
•Measure of Moral Distress - HP (Hamric et al 2018)
Moral Distress- Team level
Post-Traumatic Stress Disorder
•Trauma Screening Questionnaire (Brewin et al 2002)
PTSD- Individual level
PTSD- Individual level
Moral Distress- Team level
Burnout- Individual level- Team level- Organisational level
Individual strategies
RECOVER
RECHARGE
Pleasant Event Scheduling
“Life is like riding a bicycle. To keep your balance, you must keep moving.” – Albert Einstein
JOB CRAFTING
MONITORING WELLBEING
60
MONITORING WELLBEING
• Renew-O-Meter• Compassion Fatigue
stresschecker icu
MONITORING WELLBEING
PROCESSING/REFLECTINGSplurge writing• 5 minutes• Pen and paper (or phone if easier)• Just write whatever comes into your head• Use this as technique especially when you
are feeling overwhelmed or mixed up or your mood changes to a more negative state
FINDING MEANING
Existential perspective – helped by mentoring
Kompanje EO. Intensive Care Medicine 2018;44(5):690-1
Disch J. Crit Care Medicine 2018;44(5):690-1
Should all PICU staff receivemandatory counselling?
Answer to the original question:
Answer to the original question: No
Answer to the original question: No but
Answer to the original question: No but• they should have access to it when they need it;
• they should be helped to understand and monitor the emotional impact of their work;
• they should have good supervision/mentoring available to them;
• their units should address the need for time for reflection and
• address staff wellbeing in protocols for traumatic incidents;
• their organisations should support work life balance;
• their professional bodies should lobby on issues related to their wellbeing;
• society should acknowledge the nature of the strain they are under and their requirements re staffing and resources
THANK YOU
“Don’t be afraid to care; revel in your humanity.
You are amazing in what you do –
you just don’t get told enough.”
Handy J. A life less ordinary. JICS 2018;19(2):21