The introduction of a Balint group in their intensive care unit has provided a valuable space for reflection outside the busy hospital environment, say Vijay Pattni, Jeff Phillips, and Rajnish Saha
The covid-19 outbreak has changed the psyche of millions of people, with many of us personally affected by the disease or feeling trapped in what feels like an endless lockdown. Moreover, the pandemic’s potential impact on the wellbeing of healthcare workers is likely to be profound and long lasting, especially given the human tragedies we are now seeing on a daily basis.
In some ways, medicine seems to have changed for the better. New members of staff, including medical students, who have been redeployed to our intensive care unit have brought a renewed energy and camaraderie that we’ve not seen before in recent generations. However, when delving further, the adverse impacts of this pandemic on the mental and physical health of frontline staff become apparent. A cocktail of working consecutive 12 hour shifts in a week and seeing firsthand the deaths of previously fit and well patients is a trying combination, even for the hardiest of intensivists. Frontline workers are scared for themselves and their families at a time of uncertainty.
Witnessing suffering is not an alien concept to those working in intensive care, but the sheer scale and speed of this pandemic has led many organisations to the realisation that further support of wellbeing is imperative to help alleviate burnout. The Faculty of Intensive Care Medicine released practical steps to promote team wellbeing in the midst of covid-19. Their recommendations ranged from providing rest hubs to the need to acknowledge anxiety and uncertainty within teams, thereby encouraging a culture of openness and discussion.
In our own hospital, we endeavoured to build further on these recommendations through the formation of a Balint group to foster a more personalised and supportive environment for staff. The premise of these groups is to use case discussions to help focus on the emotions of doctors, rather than on clinical management. The concept of a Balint group is not new, having been established by a Hungarian psychoanalyst in the 1950s, and is widely used in general practice. Its practice is also recommended by the GMC given its role in promoting reflective practice.
There is a paucity of literature on its use in intensive care and wider hospital medicine, suggesting its potential psychological benefits have been somewhat unexplored in these areas. Since no one in our team had specific training in facilitating the group, and obtaining the relevant trained personnel would have been impractical at such short notice, we informally adopted a modified version of a Balint group in the context of this pandemic. We’ve held virtual, small group meetings through Zoom so that participants can connect from different locations and we can meet while implementing social distancing.
We’ve found that allowing an individual the space to talk uninterrupted for 10 minutes is incredibly refreshing. The heterogeneity of such a group, from consultant to junior doctor, has seen genuine bonding flourish within the team and removed any forms of hierarchy—after all, we are all experts in our own feelings. This kind of structure has also promoted a diversity of thought in approaching the ethical problems raised by covid-19. Weekly Balint meetings have had an important role within our department at such a critical time by providing valuable space for reflection outside the busy hospital environment.
Certain themes and recurring struggles have emerged from the meetings, and we have attempted to directly address and work to mitigate some of these, allowing for some degree of closure for staff. One theme was telling the relatives of patients over the telephone that their loved ones are dying. This remains an unprecedented situation and perpetuates the difficulty of the grieving process for relatives, but it also evidently has a significant toll on the bearer of bad news. Our subsequent procurement of tablets and a review of hospital visiting policy could potentially change this for the better. Another theme to emerge was the difficulty of finding areas to unwind in the hospital. We therefore created a “wobble room” that gives staff a quiet space to process events and reflect on their feelings.
Encouraging staff to use informal support mechanisms, like a Balint group, in addition to high quality psychological and wellbeing services, helps to foster team spirit and cohesion. Providing opportunities for staff to reflect regularly on their experiences, rather than using single session debriefs, also has the potential to foster resilience, reduce burnout, and lower the risk of post-traumatic stress disorder.
It feels like a watershed moment in medicine. Commentators have rightly pointed out how covid-19 risks scarring patients and their loved ones, but we should not forget that, equally, this pandemic has the potential to traumatise a whole generation of medics if we don’t locally provide adequate wellbeing provisions for staff.
Vijay Pattni is a junior doctor in anaesthetics at the Princess Alexandra Hospital, Harlow, Essex, UK.
Jeff Phillips is a consultant in intensive care medicine and anaesthetics at the Princess Alexandra Hospital, Harlow, Essex, UK.
Rajnish Saha is a consultant in intensive Care medicine and anaesthetics, and lead of critical care, at the Princess Alexandra Hospital, Harlow, Essex, UK.
Competing interests: None declared.