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Providing pastoral care to junior doctors in paediatric intensive care

Authors: Joe Brierley, Christine Pierce 

Publication date:  17 Mar 2012


Joe Brierley and Christine Pierce describe the introduction of a pastoral care consultant to a children’s intensive care unit

The recent call by psychiatrists for more help for doctors at risk of suicide, which followed the Department of Health’s consultation on preventing suicide, came as a timely reminder for us to support one another.[1]

Paediatric intensive care is a stressful environment in which aggressive treatments and child deaths place emotional burdens on patients, families, and staff. Although our unit provides support to families and children during and after admission to paediatric intensive care and to some extent to nurses, little was in place for junior medical staff. We tackled this by introducing a pastoral lead to our training programme. The consultant intensivist who provides this support has no role in educational training, and so confidential support has no effect on a junior doctor’s career progression.

We report our experience in providing pastoral support for trainees in a challenging environment at a time of increased concern for doctors’ wellbeing.

Background

Our unit is a 23 bed paediatric and neonatal intensive care unit in a tertiary children’s hospital in London. It is the lead centre for paediatric intensive care in the North Thames area and the largest surgical neonatal centre in southeast England.[2] Thus the unit has a high proportion of children with complex neurosurgical, oncological, and metabolic diseases, and a high proportion of the neonatal patients transferred here have severe necrotising enterocolitis and pulmonary hypertension. Because of this complex patient population the morbidity and mortality are higher than in other units, though these are appropriate when adjusted for case mix.[3] The unit acts as a national and international training centre for paediatric intensive care medicine, with trainees from around the world.

The changing medical workforce in the United Kingdom has increased the number of trainees starting work in the unit without experience in intensive care. Some of the problems faced by trainees in such a complex environment can be especially challenging if they don’t have previous experience.[4]

When we established the role of pastoral care consultant, family and child support was provided by an active psychosocial team comprising a paediatric intensive care psychologist, multi-faith chaplaincy staff, and a social work team, together with family liaison nurses and a separate consultant on the floor each day with specific responsibility for regular updates for families. Nursing support was undertaken by nurse mentors, and mortality or difficult case reviews were held for nursing staff by consultants and senior nurses. However, nothing was specifically in place for junior doctors, although standard educational supervision was undertaken. Because of the nature of on-call rotas, junior doctors could rarely attend other staff support sessions.

It is well known that doctors have a high suicide rate, with the highest rates among anaesthetists and dentists.[5] [6] It has been suggested that doctors are likely to deny depressive illness, resort to self medication, and avoid treatment. Recognition of a pre-suicidal state may be hindered by the need for the “physicians, their family, and their colleagues to preserve a fantasy of the doctor’s omnipotence.”[7] Furthermore, women in the medical profession are at greater risk of suicide, unlike in the general population,[8] [9] and female anaesthetists have reported the intensive care environment as particularly demanding and burdensome.[10]

In several units in the UK, including our own, doctors (consultants and trainees) have died after self administration of controlled intravenous agents. Whether such acts are suicidal is not known; however, often there is no evidence of a previously hidden addiction or experimentation. Addiction to drugs is an increasing phenomenon among medical staff, with anaesthetists representing 25% of all addicted doctors, possibly reflecting occupational exposure.[11] Whether such occupational exposure is important or whether doctors have less ability to select a career appropriately on the basis of personality, as nurses seem able to do,[12] is unclear.

High intensity paediatric care environments are associated with secondary traumatisation in staff, termed burnout, secondary traumatic stress, or compassion fatigue.[13] Another concern is “jading,” a process of exhaustion whereby apathy, cynicism, and callousness replace the drive to be responsive, to make a difference, and to care.[14]

It has been suggested that paediatric intensive care medicine has a “dark side,” with trainees confronting “dark” feelings regarding their own high expectations, fallibility, anger, sense of loss, frustration, limited control, and the need to work closely with tense, grieving families. If not acknowledged, such feelings of anger, detachment, and depression may pervade personal as well as professional lives.[15]

Establishment of a pastoral care consultant

Although all members of our team and the trust’s postgraduate medical facilities supported the establishment of a pastoral care consultant, one important part of the discussion focused on whether an intensive care consultant was the best staff member to fulfil such a role. The debate was polarised between those concerned about how that individual would maintain any necessary authority gradient for day to day practice on the intensive care unit and others who believed that for trainees to accept such a role it would have to come from within the profession. The second viewpoint prevailed, and a consultant intensivist (JB) was identified. He had undergone basic training in mentoring skills and attended courses on managing trainees in difficulty and on effective communication through listening and questioning skills. It was agreed that the role should involve no educational training to ensure that interactions would have minimal impact on a trainee’s career and training.

The role was explained to all trainees, and this explanation became a regular part of the induction programme. A covenant of absolute confidentially was established unless harm to self or patients was thought likely to occur. It was decided that there should be no documentation, to facilitate confidence in the non-disciplinary nature of the support, although it was found in retrospect that this made review a challenge.

Referral to the pastoral care consultant was informal and could be from the trainees themselves, educational supervisors, nursing staff, other colleagues, or generally as a result of informal discussion with the trainees.

General proactive team building events were arranged, specific interventions were undertaken, and a number of complementary supportive measures were established to facilitate team wellbeing.

Interventions

Support provided by the pastoral care consultant

The new role of the pastoral care consultant encompassed a wide range of issues and actions:

  • Personal issues: bereavement, relationships

  • Health issues: pregnancy, stress, depression, addiction

  • Professional issues: disciplinary matters, regulatory authorities, licensing bodies

  • Overseas trainees: language courses, getting children into schools, housing

  • Confidence building: presentation skills

  • Bullying or harassment

  • Team building: social events (10 pin bowling, meals out)

  • Temporary removal of trainees in difficulty from on-call rotas (it was a challenge to avoid this seeming punitive)

  • Advising on suitability of the paediatric intensive care unit’s career guidance

  • Referral: to in-hospital counselling service; professional medical or psychological support, such as the Tavistock Clinic (a bespoke confidential mental health unit offering support, including psychotherapy for medical professionals); BMA counselling

Additional supportive measures

The development of a buddy system, whereby every trainee in paediatric intensive care is allocated a senior member of nursing staff, supports the pastoral role. Regular meetings with this senior nurse enable formal and informal feedback from nursing staff to trainees and underpin the regular 360 degree appraisal system practised by all the unit’s staff.

Protected sessions facilitated by the intensive care unit’s psychologist were also introduced to give trainees further support. Again, it was uncertain whether the unit psychologist was the appropriate lead for this, especially given the close working relationship with the rest of the team. However, there was no realistic alternative, and as the sessions are informal this has not been a problem. These sessions allow junior medical staff to spend an hour discussing difficult issues and cases and are enabled by an intensive care consultant covering the juniors on the unit. Such buy-in from the consultant staff, together with similar sessions arranged for the consultants with the team psychologist, have been important in establishing medical acceptance of pastoral support for our trainees.

Burden on the pastoral consultant

Of course, there are downsides to the pastoral consultant role. Educational supervision, while occasionally onerous, is one of a consultant’s best opportunities to mentor and facilitate the career development of trainees. There is some workload burden on the individual in the pastoral consultant role, and during crisis times a considerable proportion of the consultant’s time for supporting professional activities can be spent with just one or two trainees. However, the role of postgraduate medical education departments in the London area is increasing; and some of the pastoral roles described above, especially liaison with outside agencies such as language schools and counselling bodies, are now facilitated by our postgraduate medical education department.

Excellent support from consultant colleagues, nursing staff, and the psychosocial team has enabled the establishment of the pastoral consultant role. To ease the burden we envisage that the role will rotate among the consultants.

Evaluation

A formal peer training review has described the role of pastoral consultant as an excellent innovation; and in their annual surveys paediatric intensive care trainees have given it positive formal and informal feedback. Parents, families, and other staff members in the intensive care unit seem glad that the role exists. Although this template has functioned well for us, local adaptations would be necessary elsewhere; however, we strongly recommend that a pastoral consultant be made available for all trainees in paediatric intensive care medicine.

Our pastoral care consultant has been in place for five years and has become a valued member of the paediatric intensive care team, providing proactive support and individualised guidance for trainees in difficulty.

Competing interests: None declared.

References

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  2. Audit, Information and Analysis Unit for London, Kent, Surrey and Sussex, Essex, Bedfordshire and Hertfordshire. A review of capacity for neonatal surgery. 2006.
  3. Paediatric Intensive Care Audit Network. Annual report of the Paediatric Intensive Care Audit Network. www.picanet.org.uk/Documents/General/Annual%20Report%202010/2010%20PICANet%20Annual%20Report.pdf.
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Joe Brierley consultant paediatric intensivist
Christine Pierce consultant paediatric intensivist Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK

Correspondence to J Brierley  brierj@gosh.nhs.uk

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