A psychological support programme to help staff manage any distress in the COVID era which was rolled out in Tallaght University Hospital (TUH) and subsequently to other acute hospitals could form the basis of an on-going programme to tackle moral injury and other anxieties and pressures among healthcare staff, writes Maureen Browne.
The programme was drawn up by Dr Veronica O’Doherty, Principal Psychology Manager at the hospital and is the culmination of her long-standing interest in the need to care for the carers.
“Caring for carers (health staff) has been a special interest of mine, probably going back years to my previous life when I was a registered nurse. When I was in second year, I gave a paper on caring for carers for an An Bord Altranais conference and I have cared passionately about the matter since. We have always recognised that the work of consultants, NCHDs and nurses required supports, but that need applies to all health professionals, particularly those in direct front line provision of care. Peta Taaffe who was the Matron at that time in Baggot Street and become Ireland’s first Chief Nursing Officer said to us as first year students that her door was always open, ‘but please don’t come in with a problem, instead bring me a solution to a problem and we will see how it can be implemented.’ Throughout my career this advice has influenced my thinking. Covid 19 provided those opportunities to rapidly problem solve and act.
There has been a lot of work done on the concept of moral injury, where soldiers have to do things that don’t fit with their own moral code and as a result, suffer from stress when they return home.
“As I had experience personally of working in ICU as a staff nurse years ago I knew this would bring particular pressures on the staff “When we first discovered what was happening in Wuhan, I started researching the psychological issues that could be involved in fighting the virus; reviewing papers on Ebola and SARS COV1 outbreaks initially. By the time the first case of COVID-19 was diagnosed here in February, there was a considerable amount of original research coming out from China and indeed from other countries and I started to pull together a plan for a psychological support system for staff in our hospital. Colleagues in other acute Dublin hospitals thought it was a good idea too and developed services in their hospitals.
“Including myself, we had a WTE of about nine staff in our Department, but as our out patients were reduced, all our staff immediately stepped up to participate in rolling out a staff psychological support programme for over 3000 staff members.
“I looked at the Resilience in Stressful Events (RISE) programme at the Johns Hopkins Hospital, which prepares employees to provide skilled, non-judgemental and confidential support to individuals and groups. A few years ago, Irish psychologists had already proposed a similar programme as part of a psychosocial plan for disasters in Ireland. Johns Hopkins had free online training for a system called Psychological First Aid in which I was very interested. Our team trained up online on this and I also created a WhatsApp Support Group to enable psychologists working in other hospitals to share information and support each other. We started with psycho-educational blogs to support staff on topics such as anxiety, managing children’s reactions and how to manage feeling overwhelmed.
“Then delivering the programme was all about logistics, what the programme would look like and how we could best deliver it. Orla Spencer and Noelle O’Keefe on our team delivered short targeted zoom resilience trainings across the hospital targeted to ‘whole’ teams in the emergency department and ICU, this included healthcare assistants, consultants and porters. This was like a resilience plan for individuals and teams. Resilience is often mistakenly thought of as putting the onus back on staff and telling them to be tough and manage. But this is not what resilience is about. It is about looking inwards individually and collectively, taking decisions based on current needs and making a plan. If something goes wrong, you should have a plan as to what you might do and how you will cope. We trained people in their teams to recognise both the growth moments that can happen and that things can go wrong when you are under stress and why it’s important to ask for help. Prevention is always better than cure. Our programme was based on Johns Hopkins experience of disasters, it was about people in the field and how they managed stress and pressures. Even more recently, there has been a lot of work done on the concept of moral injury, where soldiers have to do things that don’t fit with their own moral code and as a result, suffer from stress when they return home. We also looked at the work of Professor Neil Greenberg, an academic and forensic psychiatrist, who is a specialist in the understanding and management of psychological trauma, occupational mental ill-health and post-traumatic stress disorder. He has been doing a lot of work on moral injury. He works with King’s Fund in the UK contributing to the national response to protect the mental health of NHS workers.”
Dr. O’Doherty and her staff began delivering the programmes to teams in clinical areas in April. “We got great help from the ICT Department at TUH and linked directly with Dr Alex Reid and team in the Occupational Health Department. Those working in the Occupational Health Department were at the front line of staff testing. They were extremely busy, and this was an adjunct for them to give staff a rapid response for their distress. We also included a staff call line, provided for free by the Swifqueue online platform where staff could book an appointment of their choice with one of our psychology team or through Erika Somers our psychology admin support person. In the early stages of the pandemic we manned it from 7 a.m. to 8 pm and for part of the weekend, but reduced that in June to five days a week when things improved. We were delighted to get buy in from the hospital CEO, Lucy Nugent and the senior management team which brought everybody on board and recognition that compassionate care for staff really mattered.”
Dr. O’Doherty said she thought the programme had been successful because she just saw a gap when they were in the preparedness phase for the pandemic. “I just got up and did it and then everybody could see it was a good idea. Colleagues in CHI took it up too and, led mainly by psychologists and psychiatrists there. Onsite direct provision pf psychological supports were rolled out across all the acute hospitals in Dublin. The CEOs recognised the value of directly caring for their staff. We would have loved to have provided more to more people and to provide a more extensive service, involving more reflective work on demand and onsite/zoom short mindfulness programmes, but as normal services resumed our capacity has understandably diminished accordingly”.
The programme is still up and running at TUH. Demand eased off in June, July and August, but then with the surge arising again people began to get anxious again. In September people were both exhausted and becoming anxious in different ways and the team was also seeing the physical and psychological sequalae of long term COVID. One of the Greenberg recommendations is that those staff with any mental health presentations or post Covid issues should be monitored appropriately and in TUH the psychology department is continually supporting and monitoring staff who present with issues. Dr. O’Doherty said this seems to be helping. “We are following up people and giving them review support calls as needed.”
Five major acute hospitals are conducting a research study led by Dr Damien Lowry in the Mater to determine the ongoing needs and effectiveness of staff supports provided.
She thinks that while the programme might have been instigated by COVID, it is the way to go, long term, for the health services. “Occupational health always had an employee assistance programme which was very helpful for people with psychological difficulties, but this is an immediate onsite trauma informed responsive programme and we are tweaking it all the time. There is no current agreed treatment for moral injury but certainly reflective spaces, protected peer group supports, and compassionate focused leadership are the key points. “I would suggest it is important that all managers are trained in responsive and compassionate leadership. Supportive responsive managers are a key part of the alleviation of potential staff distress. We need to take the long-term view. Prevention is better than cure and I think this would be very valuable to prevent psychological stress. It would also allow incidents involving incorrect medication or staff assaults to be dealt with on-site and support given. In these cases, the health services are wonderful at dealing with the patient, but we can forget that the staff member involved is the second victim. They need support and we also need to remember the importance of learning from these type of incidents. That’s why I think we should take the learning we have had from COVID and embed it in our health systems. It would benefit patient care hugely as staff who are cared provide better care for patients. To support this learning, psychology managers in the five major acute hospitals are conducting a research study led by Dr Damien Lowry in the Mater to determine the ongoing needs and effectiveness of staff supports provided. Phase 1 has commenced, and this will be a valuable asset in directing evidence based further enhancement of staff supports.
“One of the key phrases that came from Johns Hopkins course was that ‘you should be strong enough to stand alone, smart enough to know when you need help and brave enough to ask for it.’ This for me encapsulates how we naturally resilient we are in healthcare, yet stresses the importance of asking for help when needed. To have insider help makes a difference as we know and understand the context of the environment and the pressures in the acute hospital. The other adapted tip that came from the research in John Hopkins is the concept of a psychological buddy system. When staff are wearing full PPE, say in the ED or ICU in particular, it is for each of them at the beginning a shift to have a named buddy. Someone who will say ’You need a glass of water’ or ’Take 10 minutes,’ so that each person monitors the other because staff are not good at monitoring themselves. They can work until they drop.”
Nationally a senior level team are also working hard on a timely review of the psychosocial response to support healthcare staff and our communities in Ireland. I look forward to embedding the learning and maintaining current onsite supports for staff and post Covid which would provide long term benefits to the whole health service”.
RCSI in collaboration with HSE: Conversations that Matter: Organisations That Take Care of Their Staff in COVID-19.
Youtube Link to the recording, also available via RCSI website Conversations that matter series.