Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

So the first thing I want to talk about very briefly is what I'll call psychological safe space. It's important when we are under stress that we have somewhere that we can go to think, to reflect and to gather strength. And as this slide says, it's preferable that you share that space with at least one other person you trust as we have found in war in other places. And during the COVID pandemic, the volume of work and the pressure on staff may be so great that they're forced to keep those thoughts inside themselves for a time. But it's very important that leaders make sure that everybody has an opportunity to reflect when it's safe to do. So when I was talking recently with trainees in pre hospital emergency medicine in the UK, I stressed several of the things in the bottom half of this slide. And they looked at me perplexed. I don't know that anybody has ever suggested to them before that they think about themselves at intervals in the work they're doing that. They think about their colleagues and they think about the team of which they remember in order to be able to reflect later in the military, we have talked about having buddies that is somebody who checks your equipment for you because you can't see it all yourself and somebody who thinks about your safe space. And I'm saying that we should be doing that not just in wartime, but also in all forms of healthcare practice. It's important that people should identify secondary stresses. And I'll say what I mean by that in a minute that people think about colleagues and how they're coping and they take the opportunity to be with teams as often as possible. And if people take nothing else from this presentation, it's that that it's staying in touch with people and having conversations is critical to people's mental health. Moving on the thing we have learnt from working with the pandemic is the importance of preparing healthcare staff for what they're going to face. So here is a list of 10 things which I'll go through quite briefly um for people to take into account when thinking about preparing for things and events that are likely to be stressful. The first item is to remind our colleagues about being kind to themselves and to everybody else. People in medicine are not very good at that. If we look after ourselves, we're in a better place to help our colleagues. And the third item is to encourage ourselves and our colleagues to sustain our social connections with other people while we are under great pressure. The fourth item is to be aware of the notion of moral distress that doing things in unpleasant circumstances when people have become maimed by their injuries is distressing in its own right? But when you are forced to do that with insufficient equipment and in circumstances that you would prefer not to be engaged in, it's even more distressing. I have just been rereading some military history and that is also similar to the pandemic in that people who worked in hazardous circumstances had to be reminded, to eat, drink rest and to maintain their contacts with their colleagues. It's very tempting to discontinue supervision and training when healthcare systems are under enormous strain. But that is exactly what you should not do that as stress goes up, then supervision should also go up and that needs to be prioritized. The next one sounds strange, but when people are having to work under great pressure, they may actually become quite lonely and they won't want to talk about it. But in fact, we showed in a variety of different disasters that this is the case. And so recognizing that is critical, we should make support for staff working on the frontline visible that is important to making sure that everybody else thinks it's legitimate. I'll deal with nine and 10 at the same time, it's important to follow assessment and treatment protocols and to be aware of official guidance because they protect people from feeling guilt about and not doing enough later, this is a very quick slide. What I'm showing is some of the things we have written about this. And I want to point out the one in the middle valuing, start valuing patient's in which we suggest that looking after the staff is a very important, first step to caring better for patient's at the bottom are too U R L S for where you can find that report. And also where we have met, we have made a video presentation um of a lecture like this. In the rest of this presentation, I'm going to talk about what is distress about primary and secondary stresses and a model for caring for staff of healthcare services. It consists of three main components, dealing with people's well being, dealing with their psychosocial needs, which is mainly about their distress, which may not go away immediately and then about how to recognize whether people are mentally unwell or not and might need a specialist referral, the important thing to realize. And I think that must be very, very obvious by now, but people who are not involved don't necessarily understand that warfare in the 21st century as compared with warfare 100 years ago is essentially warfare among people. It's among the population. And so we have two big blocks of people involved, the population that is affected, but also the soldiers and the staff who endeavor to intervene with that in mind. I shall focus in this talk on the staff who try to intervene and we know that they are at risk, not as much at risk of the psychosocial effects as the general population, but more than people who are uninvolved in these circumstances. The staff of healthcare services particularly are more at risk when Children, older people and disabled people are involved in the war when colleagues are injured and when there has been deaf in these circumstances, many responders feel they should have done more and that may stay with them for a long time. And that is much more likely to happen where there's little or no perceived support from family, friends and colleagues and where there are other stressful things going on. At the same time, stress may manifest in the form of physical complaints, but particularly in increased use of alcohol and drugs distress is the most common experience and I'll say a bit more about that in a minute. And there is a range of other psychological, social, psychiatric and neuro psychiatric problems like grief, substance misuse, depression, anxiety disorders, PTSD cognitive changes for a substantial minority of people. But severe levels are rare in more than 30% of people. But distress is usually experienced by nearly everybody. We know that war is liable to cause moral distress and moral injury for people who respond to the needs of others and particularly for soldiers. But one of the most important effects is the erosion of interpersonal relationships and a sense of community that can disrupt the social context in which people and groups of people function. So we've known about this for the some, some time, but that is probably the most serious psychological impact on, on people of all of these things. People ask me what happens when these kind of events are repeated. So what we're likely to see is higher levels of distress and possibly greater levels of mental disorders in due course of great importance in the long term are the indirect effects they're caused by changes in the social conditions that shape mental health. These are the social causes of mental health and the result of many wars is that there's increased poverty, there's greater levels of domestic and community violence. Afterwards. There have been and continue to be threats to human rights and changed social and societal relations. Of those four things are probably some of the greatest reasons why people suffer the mental effects of warfare for some years into the future. Now, I want to talk about distress. There are four broad sorts of reactions that characterize it. They are emotional reactions, thinking or cognitive reactions, social reactions and physical reactions. In each of these columns. The experiences in white are common but the experiences in green have worse prognosis. Let me give you several examples. Guilt is a rather worrying development and avoiding other people isolating yourself is also has effects on people that can be serious because people disconnect themselves from other people who might help them impaired concentration and memory are common. And that's probably due to a change in our psychology when we are under a great deal of stress. Other changes to the way patterns of thinking are more worrying, not sleeping, well, reduced appetite and lower energy are common indicators of distress but being over aroused and, and having headaches are not helpful signs after the bombing in Manchester in 2017, here is a list of the most common indicators of distress, having strong feelings and being anxious and fearful that things will happen again is common. Sometimes people are vigilant in public places because they fear what might happen and that may result in them withdrawing socially. And that's probably the most worrying symptom we found in the British military. My colleagues have talked about acute stress reactions and it's again, despite having a worrying title is not necessarily an indication of lasting illness. The experiences include intrusive memories and upsetting dreams about what people have been through. More severe is when people actually feel as though the event is happening all over again or having bodily reactions when being reminded of what took place, being irritable or having outbursts of anger and being jumpy or being startled that something unexpected may also occur. So it's quite easy to see how severe forms of acute stress we're called shellshock in the first World War. Let me move on to primary and secondary stresses. So, primary stresses are those stresses that are inherent in the circumstances in which we find ourselves. And it's very easy to see how in times of war, there are many things exceedingly stressful. However, we should be careful about describing the stress that staff of responding services experience as necessarily resulting from what they've witnessed, the work they have done and the work they've not done. And that is because there are a huge range of secondary stresses that spring up in um illness outbreaks and in warfare that are very likely to be the very potent causes of stress. So we need to look further a field rather than just make assumptions during the pandemic. Even staff in the UK had difficulties getting showers and reliable access to food in hospitals that was extraordinary stressful on top of dealing with infected patients'. And the other cause of secondary stress is is how societies respond to events like warfare. If they respond energetically enthusiastically and ensure that there is a good supply of resources, they can keep the secondary stress is down. But without resources, staff are exposed to unnecessary stress is though understandable, you will see that I am taking a very socially orientated approach. These are not the kind of experiences for which people should receive medications, but they are the kind of circumstances that for which people require social support. There is growing evidence that how people cope, adjust and recover in the face of extreme stress turns on social support in this context, social support consists of social interactions that provide people with actual assistance but embed them in a web of relationships that they perceive to be loving, caring and readily available. The circumstances of war are such that soldiers who are injured and the public who are directly affected, look to healthcare staff for this kind of social support as well as dealing with their wounds. And in order to cope with that, the staff of healthcare services need someone and somewhere to take their concerns, their buddies, their leaders, they're managers, they need social cohesion and cooperation, ineffective teams and services and a sense of belonging to a valued social group and community and that requires leadership. So I think the early interventions to support healthcare responders now become predictable. They require first early intervention and those early interventions should consist of general support and pulse during the environment in which they work rather than psychological treatments. We need to make sure that members of healthcare teams have opportunities to restore their faith in their own abilities, to do good things. That's what I mean by agency and perceptions of themselves as effective people. Third, practical interventions should be based on the acronym pies. This was invented by the French in the first World War and there is no evidence that it prevents people developing mental ill health. Um in the face of war and pies stands for proximity. That is providing people with the support they need close to where they are rather than sending them somewhere else. Providing those responses early and without delay. That's immediacy with an expectancy that people will recover and the responses that people should be offered in the first instance, should be simple. The fourth intervention is about secondary stresses clearly in warfare. It is difficult to reduce the severe impact of the primary stressor which is the war and the resulting stress and distress that comes from it. But we've looked at and researched secondary stresses in particular in the many refugees and internally displaced people who are thrown up by warfare. If we have war among the people, as we certainly seem to do in the last conflicts. We also uh and we should think about creating peer support programs within teams at work. And we have experimented with doing that during the pandemic and during severe incidents and it works very well in terms of having someone else to who people to concern for that. Um Psychological space. This has led us to create this kind of flow diagram for the interventions that we ought to make to support healthcare staff in the face of extreme stress. A well being agenda in green to act in a preventative way. The psychosocial agenda for helping people who are struggling to cope with the distress, the experience and having access to mental health services for people who become mentally unwell. And you'll notice here, peer support. And I will say just a few words next about that, the notion of peer support is based on the relationship between appear and a supporter. So this could mean a member of a surgical team and somebody in that team who has been had a certain degree of training, but not a lot of training to actually be able to listen to people. It's about active listening, so it must be voluntary so that people can engage or disengage as they choose, we have created services of this kind in intensive care units in hospitals in the United Kingdom. And the result is that people have felt better, their absence from work has reduced and they're leaving high intensive and stressful practice has reduced. And finally, I just want to summarize in these 10 platinum approaches to helping people faced with extreme situations and helping them to not become casualties themselves anymore than is absolutely unavoidable. It's about intervening early to support people who appear to be distressed by bolstering the recovery environment and listening rather than therapy or counseling. So we suggest that everybody, every team in healthcare has one or or more people who are trained in this approach. And an important component of it is learning active listening skills. It's about seeking out and putting right secondary stresses so far as is possible. And in that respect, there is growing evidence that social support is vital and that means that everybody should have a buddy and everybody should be a member of a team seven is that people's senses of their own personal effectiveness and achievements are important to their recovering from being distressed. And if we apply these things using the acronym pies, there is evidence that we can reduce the prospect of people developing mental ill health. But no matter how good we are at doing these things and looking after staff in healthcare services, we need to develop care pathways that deal not only with well being and their psychosocial needs, but are responsive when people do develop mental health disorders. And that means being clear about who might and who might not benefit from a medical approach involving things like cognitive behavior therapy. Some people may develop diagnosable mental disorders for which they require specialist medical care. That is true, but most do not.