Psychological first aid in the intensive care unit

Abstract

The intensive care unit (ICU) is a stressful environment for patients and their families as well as healthcare workers (HCWs). Distress, which is a negative emotional or physical response to a stressor is common in the ICU. Psychological first aid (PFA) is a form of mental health assistance provided in the immediate aftermath of disasters or other critical incidents to address acute distress and re-establish effective coping and functioning. The aim of this narrative review is to inform the development and utilization of PFA by HCWs in the ICU to reduce the burden of distress among patients, caregivers, and HCWs. This is the first such review to apply PFA to the ICU setting.

Key Words: Intensive care unit; Stress; Distress; Psychological first aid; Mental health

Core Tip: Psychological first aid is a form of mental health assistance provided in the immediate aftermath of disasters or other critical incidents to address acute distress and re-establish effective coping and functioning. It can be applied in the intensive care unit setting to patients, families, and healthcare workers.

INTRODUCTION

The intensive care unit (ICU) is a stressful environment for patients and their families as well as healthcare workers (HCWs)[1]. Stressors such as codes, procedures, family meetings, and deaths abound in the ICU; therefore, distress, which is a negative emotional or physical response to a stressor, such as emotions of sadness or frustration or physical symptoms including diminished hunger or chest pain, is common among ICU providers, conscious patients in the ICU, and families[1]. Distress can be debilitating and may warrant interventions such as active listening, group discussion, and other supportive measures. Because training on measures to alleviate distress is not a required part of critical care training, many HCWs know little about how to assist patients and families or their own colleagues in coping with distress in the ICU.

Stressors that occur on a large scale and affect many individuals are known as disasters. Because disasters are just one type of stressor, we can apply the best practices learned from disaster mental health (MH) to the stressors associated with healthcare work[2]. One such practice is psychological first aid (PFA). PFA is a form of MH assistance provided in the immediate aftermath of disasters or other critical incidents to address acute distress and re-establish effective coping and functioning[2,3]. It was developed through expert consensus and is flexible for use in various settings, populations, and cultures[3]. PFA can be provided by both MH and other critical incident responders[3,4].

Several PFA programs, including RAPID-PFA at Johns Hopkins[5], have been instituted to train HCWs and emergency personnel on MH aspects of emergency response. However, most PFA programs, including RAPID-PFA, train workers to respond to major traumatic incidents but not to daily stressors occurring in the ICU such as codes or difficult family meetings, which are very stressful but inherently different from mass casualty events based on size and severity[3-7]. It is therefore essential to adapt PFA to the ICU setting. Studies have shown that when HCWs are offered PFA training during a pandemic, lack of staff time and inability to meet in person substantially limit the uptake and effectiveness of PFA[7,8]. Teaching PFA to HCWs at high risk for distress, such as ICU workers, in times of normative operations may better prepare them to support their patients, families, and one another through daily stressors occurring in the ICU as well as equip them for disasters such as pandemics or mass casualty events[9].

The aim of this narrative review is to inform the development and utilization of PFA by HCWs in the ICU to reduce the burden of distress among patients, caregivers, and HCWs. This is the first such review to apply PFA to the ICU setting. There are several available versions of PFA, but they generally contain all the same basic elements[3-5]. The paragraphs below will summarize the elements of PFA.

ELEMENTS OF PFA

Being there

The first element of PFA is simply being there, or the “ministry of presence”. Effective providers of PFA aspire to be present, unobtrusive, helpful, and compassionate, with sensitivity to interpersonal cues about touch, distance, and privacy. In disasters such as terrorist attacks, natural disasters, or mass casualty events, being there involves attending to immediate physical needs, providing comfort, and addressing concerns. In the ICU, HCWs can be present by spending quality time with patients and families negotiating difficult circumstances and with their own colleagues who may be facing significant stressors. They might sit with a grieving family even after the family meeting concludes or pause rounds to help a colleague who has just endured a difficult procedure or code. Because HCWs are physically present for extended periods in the ICU to witness stressful moments in medical care directly, they can reach more individuals than can point-in-time services such as formal counseling offered by external providers outside the critical care team.

Safety and stabilization

In natural disasters or terrorist attacks, provision of safety and stabilization entails removing people from avoidable exposure to physical harm. Physical harm may occur in the ICU setting when members of the healthcare team or others are physically or verbally attacked by patients or their family members. In such situations, notifying security and physically redirecting HCWs and others from harm may be necessary for initiation of PFA. More often, before a conflict escalates to physical violence or self-harm, individuals may lose the ability to function appropriately or even show warning signs of potentially disruptive behavior. For them, safety and stabilization may be established simply by giving the person a few minutes of privacy to process the situation and calm down, by enlisting the calming assistance of friends and family, or even by separating disruptive individuals from others to facilitate de-escalation. For anyone contemplating impending harm to self or others, HCWs are advised to seek security and/or medical assistance immediately and not leave the person unsupervised.

Skilled listening

Skilled listening is a central part of PFA. In administering PFA to other HCWs in the ICU or to patients and their families, HCWs attentively listen to their stories with concerned interest. They can invite individuals’ thoughts, gently probing for details while avoiding the revisiting of unnecessary painful details of the stressful or traumatic experience as indicated by the person’s apparent reluctance to discuss them.

Medically relevant information is obtained through genuinely interested listening to the distressed person’s reports of stressful exposures, injuries, medical history, medications, and psychiatric history. This information is best elicited without forcing discussion of difficult feelings, which may be counter-therapeutic in the immediate aftermath of a critical incident when strong emotions may be overwhelming. For example, if a resident is distressed after a procedural complication, sitting with the resident and asking “How are you doing” and then pausing to listen without interruption is far more helpful than probing for the details of the procedure.

The best way to develop skilled listening is to practice under the observation of a trained professional who is adept at this practice. Appendix A contains several scenarios that HCWs can use for role playing to learn the practice of skilled listening.

Education and reassurance

Helping people understand what is going on with the situation and within themselves is a vital function of PFA. The type of education and reassurance provided in PFA depends on the characteristics of the individual and the stressor. Individuals with no psychiatric disorder may be comforted by normalizing and validating their emotional responses. They can be reassured that disturbing feelings they may have that are foreign to their experience do not necessarily indicate psychopathology and that most people do not develop psychiatric illness after exposure to intense stressors, including major disasters[2,6,10,11]. In the ICU, HCWs may apply the principles of education and reassurance to grieving families or other HCWs experiencing significant work-related stressors.

If a psychiatric disorder is suspected, the PFA provider may need to help the person-overcome stigma to facilitate acceptance of psychiatric evaluation. It may help to discuss the biological basis of emotions, how medications work to help resolve emotional difficulties, and that treatment is effective. Of note, it is important for critical incident responders to know that according to current diagnostic criteria in psychiatry[12], naturally occurring medical illness, even if life-threatening or occurring in a pandemic, is not defined as a traumatic event, and thus post-traumatic stress disorder (PTSD) is not an expected outcome. This does not imply that stressors not constituting traumatic events by this definition are not important or can be discounted, because many stressors may be more severe and have more negative MH outcomes than events formally qualifying as stressors. In other words, it should be emphasized that trauma and PTSD are not required for psychiatric evaluation and care to be warranted. Psychiatric disorders that most commonly begin after stressful events include depressive and anxiety disorders. Psychoeducation can reduce the number of sick days taken by individuals with psychopathology and can improve willingness to accept psychiatric evaluation[7,8].

Risk communication is an important skill set within the education and reassurance component of PFA because it informs and guides people to make the wisest decisions and choose the safest behaviors[2,10]. Clear and consistent risk communication delivered by trusted members of the leadership team is particularly important in the ICU during times of crisis such as pandemics, because it helps keep HCWs informed and safe and increases confidence in the leadership’s guidance and support of workers at the institutional level[2,10].

Coping and stress management

PFA may begin to address coping and stress management by giving individuals initial permission to cry, feel bad, be nonproductive, and focus on themselves for a limited time. Application of crisis coping skills can help individuals regain control of some aspect of the situation and start to restore routines, which can help them start to address their situation and begin to feel better. Coping skills include effective utilization of social supports as well as personal techniques such as positive self-talk, exploration of perspectives and meaning in the experience, self-care, and appropriate use of humor. Some people are prone to digress to extremes (e.g., excessive eating, foregoing rest and sleep) in crisis situations, and PFA for them may include reminders to seek balance in self-care activities and avoid excesses.

In times of ordinary ICU operations, stress management may include purposeful self-care practices such as finding down time and seeking support from family and friends away from work[2]. Especially during times of crisis in the ICU such as a pandemic, HCWs may need to advocate for their institutions to broaden the pool of front-line workers and ensure sufficient time away from work for recovery[2].

Problem solving

As problems arise following a disaster or other major stressor, overwhelmed or distressed individuals may be assisted with problem solving by someone who is not compromised by such extreme experience and has a clear head to lend sound reasoning skills. In the ICU, overwhelmed HCWs and especially trainees can be aided with practical problem solving through techniques of making lists, prioritizing, weighing advantages and disadvantages of possible choices, breaking problems into manageable units, and maintaining sight of the larger perspective and progress. Assistance with problem solving may also be applicable to patients and families who are facing difficult decisions. People may be able to grow and gain strength from overwhelming experience if they have guidance and encouragement to explore new behaviors and develop previously untried problem-solving skills.

Connect with support

Sources of support that can help people in times of crisis include not only family and friends but also formal support services. Psychosocial service professionals such as social workers and HCWs have skills and resources that can hasten the road to recovery. Research has shown that people who lack social supports may have heightened risk for psychological adjustment problems following trauma or major stressors.

Asking patients to consider involving trusted friends or family in difficult discussions may help them navigate difficult news and medical decisions. Similarly, allowing an ICU team to gather together informally outside of work to spend time together and discuss their experiences can hasten their return to usual operations following an intense stressor.

Acute symptom management

After critical incidents, the most bothersome early incident-related symptoms are likely to involve hyperarousal[6,11]. Physical hyperarousal symptoms may include insomnia or jitteriness and restlessness. Emotional hyperarousal symptoms may include irritability, nervousness, anxiety, worry, fear, panic, and inability to concentrate. Tools to facilitate distraction from immediate distress can be helpful for symptom management, including, for example, engaging in absorbing and enjoyable activities such as games, puzzles, reading, movies, music, and dancing[10]. Relaxation techniques such as deep breathing, muscle relaxation, and pre-hypnotic induction through listening to relaxing scenarios can help ameliorate hyperarousal symptoms. Examples of relaxation exercises are provided in appendix B. Individuals with overwhelming symptoms may warrant short-term pharmacotherapy by a psychiatrically trained physician to reduce tension[10]. In the ICU, both distressed HCWs as well as patients and their family members can be led through exercises to help calm their symptoms. Additionally, HCWs can be given time away from work to engage in pleasurable and engaging activities that they enjoy to distract them from their symptoms.

Know when more help is needed

Specialized assistance may be needed for individuals with persistence or escalation of intolerable symptoms despite interventions, pre-existing psychiatric illness requiring ongoing treatment, or requests for additional help. For these individuals, timely evaluation and/or stabilization by a psychiatrically trained clinician may be warranted[2,10]. Urgent help may need to be enlisted for acutely worrisome behavior such as indications of impending harm to self or others or for disorientation or altered level of consciousness, and for individuals who are too overwhelmed to be able to provide essential care for themselves and/or dependents[2,10].

During times of crisis such as pandemics or mass casualty events, institutions can mobilize psychiatric professionals and institute psychiatric screening measures to systematically identify high-risk individuals[2]. ICU clinicians providing PFA should familiarize themselves with MH resources that are available inside and outside of their institutions so that they will be able to help connect colleagues with psychiatric assistance. National crisis hotlines are also available to everyone (call or text 988 for the National Suicide Prevention Lifeline). Institutional leadership can facilitate this PFA component by clearly communicating available MH resources directly to employees[2].

Caring for the caregivers

Critical care workers or family members of disaster victims can themselves experience psychological distress or even become full-fledged MH casualties in difficult circumstances or critical incidents[6,10,11]. Factors contributing to caregiver distress include extended and severe exposure to intense stressful circumstances, exposure to injury and infection, worry about loved ones involved in the incident, loss of personal property, difficult working conditions, long work hours and cumulative fatigue, separation from usual supports and familiar comforts, and ethical dilemmas[6,10].

All elements of PFA can address general distress of clinicians in the ICU, but this last step focuses on their needs specifically related to critical incidents. For this component, caregivers can follow the same basic advice they give to those they are assisting, including rest, nutrition, hygiene, exercise, relaxation, and healthy balance.

Caring for colleagues may particularly involve offering positive support and encouraging words, helping out with their work, monitoring their fatigue levels, and facilitating restorative time together. Restorative time can include breaking bread together at meals, gathering to share experiences, and conducting follow-up meetings to review operations and work out any kinks for next the time.

Healthcare organizations can assist critical care personnel with distress by providing equitable workload distribution; observation of workers for distress and fatigue; risk communication and active listening; compassionate gestures; encouragement and recognition of service; and organized peer support, crisis counseling, and formal group therapy or individual treatment[2]. It is best for institutions is to prepare in advance by establishing these types of functions for HCWs that are ready to go when the need arises[10].

CONCLUSION

Stressors abound in the ICU, and distress is common among ICU clinicians as well as patients and their families[1]. PFA can be implemented for these groups to address acute distress and re-establish effective coping and functioning. Healthcare organizations can be tasked with partnering with ICU clinicians to facilitate application of the elements of PFA through institutional supports[2].

This article has detailed the use of representative PFA practices for HCWs, patients, and caregivers under the ordinary stresses of the ICU as well as during extraordinary circumstances such as individual critical incidents and collective disasters, especially pandemics such as coronavirus disease 2019. The narrative review format of this article may limit reproducibility, and there is no available evidence to assess the effectiveness of the exercises provided.

Further, while this article provides practical guidance for the general application of PFA in these settings and circumstances, development of formal specific procedures for the ICU is needed. Then, research is needed to measure outcomes such as burnout scores and prevalence of psychiatric illness, assess effectiveness, and inform further improvement of the use of PFA in this setting and in resource-limited settings. Formal development of PFA practices has the potential to greatly reduce distress and improve the effectiveness of HCWs in various ICU settings and circumstances.