‘The patients are just so sick…’

How did you come to work in critical care?
Before I went into my clinical psychology training my areas of interest were quite medically based. Once I qualified I came to a bit of a crossroads – I could do a job in a community mental health team or I could go for a job in nephrology. The nephrology job was really exciting because they had never had a psychologist in place before, so at that point I thought 'I'll go with the thing that sounds really different and innovative'. I've never looked back since.

About six years ago my husband, who's also a psychologist, was looking to change jobs and found a really interesting job in South Wales. I started looking for jobs in South Wales too and the critical care one was the most interesting because it was adults and paediatrics and a good third of the job was about staff wellbeing and organisational wellbeing, which I had developed an interest in in my last job… I had worked with the Trust HR team supporting struggling teams, and considering staff wellbeing. 

Whenever you read in the newspaper that a person's condition is 'critical', that means they are unwell enough to come to critical care, which is also called intensive care. So many different conditions, a mixture of kidney patients, heart patients, respiratory patients, physical trauma patients. It felt like a combination of every bit of health I'd dipped my toe into before, plus staff wellbeing. That's how my journey came about – organically but with a little bit of design. 

You've been working on the frontline during the Covid-19 pandemic could you tell me about that experience so far? 
It's been hugely increased workload for a start, the patients are just so sick we can't get in to see them, and we're seeing them further down the line than we normally would. Our patient work has tripled with little extra resource. The relatives' work has massively increased as well, because the relatives are less able to be supported by the process of coming in and visiting. 

In the middle of all of this we were also setting up a more robust psychology follow-up service for patients. It's part of NICE guidance for critical care then we offer a follow-up review two to three months down the line, post-hospital discharge. Most patients who experience intensive care don't remember an awful lot of it – that's the nature of sedation, it actually affects long wave sleep and the way you lay down memories. As time goes on and we lighten sedation patients often experience delusions and hallucinations and can be very confused and disorientated, which is what we call ICU delirium.The memories of this remain with some patients, and leave them with a sense of threat and trauma… much of follow-up allows for sense making and processing of this. There's also a lot of other stuff which is part-psychological, part-physiotherapy, part-medical, which is filling in the gaps and making sure people are on the right pathways. 

I've noticed the difference between Covid patients and other ICU patients is the intensity of the delirium seems to be greater, the hallucinations are far more vivid than I've ever come across. People are left with worse fatigue and it's hard to know whether that's post-viral fatigue, or if it's related to ICU deconditioning. 

What's really positive from a public point of view is they understand what critical care is, they feel more able to access information and read up on it, and they're more clued in to the nature of this disease, and what to expect. The social support around it is huge because obviously people are incredibly worried about people who've been in hospital with Covid. We are seeing a lot of post-traumatic growth where people are so grateful for the hospital, so grateful for the team, so grateful to be alive, actually, that it feels like a joy and a pleasure to get home no matter what.

What will your secondment with the Intensive Care Society involve?
I'd been doing some work for the Intensive Care Society for wellbeing anyway and when this project came up they invited me to apply for a secondment. Our aim is to be responsive to critical care staff psychological needs during the pandemic, but also to embed more psychologists into services to enable wellbeing in the long term.

Along with critical care doctors Laura Vincent and Peter Brindley, I published an article on the results from a survey of the UK, critical care population in 2019. In essence, we saw that about one in three ICU staff were experiencing high levels of burnout prior to the pandemic. Staff wellbeing in ICU is really, really poor, and so it's crucial we do something about it. It's not all about sending people to a psychologist, it's about embedding psychological health within the system. 

We're hoping to embed a peer-support model to train up units and create systems of peer-to-peer support that will then be supervised by psychology. We want to embed clinical psychologists into units where they don't already have them so that they can provide that one-to-one support and help with the system, with teamwork, and with group facilitation. In the larger units we're hoping that they will match fund with us and then we can provide a service for patients and staff as well. We have another longer-term aim which is about setting up the resources to develop the wellbeing culture within ICUs; a lot of that will be online and through a series of webinars. We want to look at ICU leadership and support leaders, because our best evidence about wellbeing at work is actually about who leads you. It makes a massive difference to your wellbeing if you feel listened to, understood and enabled by your leader. That's really hard to do in an ICU environment which is 24/7: it's very hard to have a single leader, there's often multiple team leaders and different kinds of personalities, so it's quite a complex system. 

- The Intensive Care Society is fundraising for the wellbeing work Highfield is involved with. 
See also our interview with Dr Highfield from earlier in the pandemic.