Psychological Support in the ED

Psychological Support In the first wave, the whole world was with us, the NHS.  The  freebies heading our way persist and some support still exists, but a lot is different. We know it is hugely demanding both physically and mentally for all staff, with lots of moral injury, on a background of exhaustion. As individuals we need to look after ourselves, and our team, whilst recognising the positive effects of stress! We’re in the active phase, and what we do there will help in the recovery phase. RCEMLearning has lots of wellbeing resources available here and RCEM has an excellent whole page of resources highlighted here, as well as many key documents from the sustainable working group including the wellness compendium, when a colleague dies – and much more. There’s many resources already in existence – one of many twitter threads starts here, liason psych advice here, fabulous learning from excellence summary, pre-hospital advice here, and there’s a useful BMJ summary of self care here too.  Even HEE have a separate wellbeing programme, and the London School of Paediatrics created a wellbeing book! Other places have released lots of guidance too including Cardiff intensive care here, and there’s an e-learning package on psychological wellbeing from WRAPEM, and another from University of Nottingham here. Here are our top tips for advice to give your team, and yourself.

1. Be in top physical form

We know sleep (here and here covid specific here) nutrition and rest are really important, especially as we have a lot of video call fatigue. They probably have a good effect on our immunity. View our previous articles (compendium here) already and highlight them to your non EM colleagues. RCEM is really clear that now, more than ever, we need to look after ourselves, and everyone else, including our patients. It’s also worth mentioning that all the hand washing can cause havoc with your skin (although what all these people were doing beforehand I do not know)! Moisturise well! If your hands have started to crack, these tips from a dermatologist are fab, and BAD released a statement too.

1. Recognise and manage your stress

Read the RCEMLearning Stress Blog. Don’t just read it though, talk about stress and how to manage it with all your colleagues both in EM and out of EM. I delivered the simple stress lecture – and opened by saying “How do you know when I’m stressed”. At least 5 accurate signs were presented. When I asked “how do you help when I’m stressed”, the room went silent. By talking about it, it really helped normalise the potential of stress. Everyone in the room was stressed about coronavirus on about a 7-8/10 – apart from one person who hadn’t been in the clinical environment, so maybe we’re not helping ourselves! A stress management course online starts soon! Remind People to be Kind: Some stress comes from not being able to help. Encourage non front line staff to think about their neighbours and community initiatives. Initiative to help GP services could be used in hospitals – engage your patient participation group? It’s not just everyone else that needs to be kind – leaders need to be kind too.

There’s lots of mindfulness apps available here with discounts / freebies for NHS staff, and a summary for “NHS people” here. There’s a new twitter handle just for wellness – @19_wellness with a supporting facebook group, and an fab  overview of everything with bags of awesome resources from NHS in mind. There’s a new PHP supportline available too. There’s some specific resources around reducing coronavirus related anxiety and some meditations here (found from twitter). The “young person” resources might be good for the young or the old, and this imagined section resources is ideal for children. There’s also some more generic wellbeing tips available from “live life to the full” with some lovely posters for HCPs here, and there will be some regular caring4nhspeople webinairs, as well as lots of blogs and resources from the Maudsley. You’d be surprised if we didn’t mention resilience – have  a look at this resilience blog from T2 here. Hypnosis is clearly very beneficial here – have a look at some of the relaxations on NHS in mind, or the 5min relax and recover. More will be coming from ISH – some here already.

1. Recognise and manage everyone else’s stress

Consider why people are anxious – just because you’re not (although you probably are!), doesn’t mean they shouldn’t be – read this article on recognising anxieties.  Maybe they don’t know from a patient perspective how ventilation works? This is discussed by St Emlyns here.  Children might have different anxieties – discussed here. People might just be in a different spot to you – I think most people in EM have moved through the fear zone into the learning or growth zones – not everyone is there yet.

There’s a useful leaflet from Mind about reducing general anxiety, and an excellent article on managing your own mental health from BBC coronavirus. These resources will also be useful for your patients COVID related anxiety. This from the intensive care society starts by reminding us to make sure you only get updates once or twice a day. Encourage this from your team, to help them help themselves. Have some good email and especially whatsapp management strategies – remember whats app is often on people’s personal mobiles, so they can’t ignore it. If you check for updates every five seconds, you will burden yourself with anticipatory stress. Whilst you do this, only contact your nosey friends once or twice. We all know the people we mean – those who are only in touch when something bad happens, or they want “inside information”. They’ll take your time away, and suck you into making this a bigger drama than it is. It’s also worth remembering your wider team. Clinicians are aware of all the resources being thrown at them, but make sure the non clinical staff are too. The effects of stress on teams are widely known – do what you can to minimise it.

1. Keep Laughing and Keep Leading

It’s OK to laugh. These are challenging times, yes, but Laughter can enhance immunity–  and we know it reduces stress. Social distancing doesn’t mean emotional distancing. Your team need you now more than ever – some great tips here. Who is self isolating and needs to check in? Who is poorly and needs a 5 min check in chat?

1. Debrief Often

Debriefing is everyone’s responsibility, and you need to encourage your team to start doing it now – debriefs shouldn’t just be after cardiac arrest. Check in and debrief with yourself – some great tips here, and a non covid related debrief podcast here. Not all debriefing needs to be formal – I love the idea of a wobble room, and even just asking “how are you“, and not all debriefing needs to be after the event – consider a time out. Most of us have been debriefing for a while, but might run out of time, and the headspace. Contact your chaplaincy service, and any psychology services – ours are going to be running a daily debrief drop in session with our psychology colleagues to make sure night and day shift can attend. A “4 o-clock club” is a similar approach. For people new to debriefing, the “TAKE STOCK” principle will be useful, and there’s another useful COVID specific prompt here. There’s a trial of an online debriefing service here. A hot debrief is recommended, but not compulsory. It is an emotional release and a “lessons learned” review carried out there and then after the incident or exercise, when all the key people are still present and any lessons learned can immediately influence future events. Minor details aren’t lost because of time delay, or a later emphasis on the bigger issues. We have prompts available on our ED bereavement checklist to attempt to normalise the debrief process – often starting is the hardest part! The cold debrief structure is often similar to the simulation “debrief diamond” or an after action review. The resus team may be able to help arrange this. An alternative model for a cold debrief is one which focuses on the emotional impact of the event and the ways in which participants are coping with this, and potential lessons to be learnt are not addressed, to enable people to speak freely in a non-judgemental environment. This model might be particularly useful to support the psychological well-being of staff.

1. Arrange Practical and Wellbeing Support

It’s the little things that make a day at work better or worse. Worrying about whether your period will start, or if you’ve got enough food at home won’t make it better. But what about if you need to shower after a patient coughs all over you? What about if you’re too tired to travel home? Practical ideas like a “fare box“, “too tired to travel home” box, peer support for all things, including grocery supply are useful. Of course, if there’s space in your hospital some porta-homes would be useful for staff isolating from family, or who can’t get transport to work. The extroverts might like some interaction – maybe a zoom quiz or something? We at LGT, had to go one step further, and our period SOS box has got organic supplies (thank you Freda), and a nice little bit of period specific relaxing (slow version here – if it helped you let us know!). The doctor sickness record we’ve been keeping has tick boxes for when you last completed a welfare check. Ideally we’ll do that every day. Pragmatically, we’re not sure. We’re encouraging our junior doctors to form welfare groups, so they can check in on themselves.

7.  Allow grief  Many trusts have banned visitors, even for the dying. This is leaving a lot of HCPs as the last person speaking to a dying patient- and this is taking a toll. We deliver people out of this world, as much as a midwife delivers them in – but it isn’t always easy. Take a moment to honour, and grieve for your patient who has died. We hope none of you have to grieve for friends or relatives, but you might have to. Un-doubtably you will have to support grieving relatives of patients. There are plenty of tips here from thegoodgrieftrust, and tips for for grieving children here. Not all deaths will be due to coronavirus, and other support societies do exist eg. brake for victims of road traffic accidents.

8. Support Family  Acknowledging that your doctor’s family is supporting them too is useful. This is a great letter from one trust. Using careful language is also important – and many using the right terminology around covid is important – original article here and twitter here.

9. Rest Well Resting is more than sleeping well. Resting is a chance to give everything to recover. We’ve made some suggestions on how reading can help, and some suggestions of what to do to help with holidays and we look forward to hearing your suggestions and additions too.

Other RCEM Learning Wellbeing Resources: We’ve signposted to the fabulous RCEM wellbeing compendium already. Do have a look at some of our other wellbeing resources – all available free of charge here.

Other Resources: HEE have created a wellbeing induction and strategy that piloted for the new transition to FY years. Some of the links they’ve highlighted are fabulous. We like: AOMRC CDC MindEd Intensive Care Society Practitioner Support and have used some of their suggestions to update noticeboards with healthy eating and financial wellbeing contributions – instead of just focussing on mental health.