'Gruelling but immensely rewarding'

I have worked at the Royal Free Hospital NHS Foundation Trust in acute medicine for most of my career as a clinical psychologist. Covid-19 has, of course, changed the focus and tempo of work for me and many of my fellow psychologists both in the hospital and around the UK. While remote consultations are now well established in health care generally and in mental health specifically, virtually all of my work in an acute medical setting remains face to face. It is difficult to think how it could be done otherwise. 

Psychologists have consulted in ICU's (Intensive Care Units), Acute Medical Settings and ED's (Emergency Departments) for years, but the wide range of medical problems seen and pace of work has differed markedly from the challenge of Covid-19. We now see almost exclusively large numbers of adult patients brought to ED's in ambulances presenting with severe respiratory problems. The majority of the general hospital is now devoted to Covid-19 care. Irrespective of the teams, units or services with which we as psychologists consult, the issues and challenges are broadly the same.  

I have worked to initiate and forge collaborative relationships with many healthcare teams. Some will have been used to having a psychologist as part of the service. For others, our role and presence will be entirely new. As most patients in hospital will be very unwell with respiratory problems, and a sizeable number will be intubated (and therefore unconscious or receiving oxygen), face to face patient consultations are rare. Almost all of my ward work focuses on direct or indirect staff support. This takes several forms.  

Being physically present on a ward is a powerful way to convey support. It may take several visits before colleagues recognise you and come to chat with you about patients or their own stress, whether it comes from their professional work or challenges at home. I have spent hours at ward rounds and lending a hand with ward staff, and it is not until several weeks or longer have passed that people then approach you seeking support. Many are tired, upset and at times traumatised by what they encounter at work and also have concerns about the wellbeing of their families.  

Everyone will now be aware that visits to hospital to support a loved one are severely restricted, and therefore stress levels in families who have a loved one in hospital may be very high. Psychologists have an important role in updating loved ones at home on behalf of ward staff so that they can carry on their important duties. It also takes time and is a cost in terms of resources for a nurse or doctor to change out of the PPE (personal protective equipment) to leave a Covid-19 secure area, and to then pick up the phone and call a relative. We use walkie talkies to share the information that is then passed onto relatives. 

There is a third area which I have become involved in. I have offered night shift support on our ICU. Of course, I have no medical training and therefore cannot carry out the functions of a highly trained anaesthetist or ICU Nurse. I have worked under their direct supervision to prone (turn over) intubated patients, pass to them pieces of equipment, record vital signs and on one occasion helped to clear a patient's airway as the anaesthetist struggled to attach a canula. It has been a steep and momentous learning curve. The most psychologically focused part of the experience has been sitting and having a coffee with medical and nursing colleagues during our breaks. Conversation soon turns to the topic of stress, trauma and fatigue. Taking off PPE reminded me how my vision and hearing had been impacted whilst on the ward. 

I know being in hospital is but one part of their illness journey and for those who recover; they will need the expertise of a multidisciplinary team which includes a psychologist in their recovery.  

I learned about collaborative care in acute medicine when I spent time with my friend and colleague Professor Susan McDaniel (past president of the American Psychological Association) at the University of Rochester in upstate New York during a sabbatical many years ago. The most important things I took away from that were:  

- Be physically present; colleagues will engage with you only if they see you 

- Don't be precious as a psychologist; offer to help on the ward 

- Bide your time; collaborative relationships take time to form 

- Learn medical acronyms; the language may seem alienating and obscure at times  
- Be humble in the presence of nursing and medical colleagues: there is a tremendous amount to learn 

- Illness mostly affects an individual, but don't leave out the family from treatment and care 

It is gruelling but immensely rewarding to work in acute medicine at this time and presents a striking opportunity to bring more psychologists in acute medical settings such as the ED ICU. 

Professor Robert Bor 

Lead Consultant Clinical, Counselling & Health Psychologist and Aviation Psychologist 

Royal Free Hampstead NHS Foundation Trust