Standardisation of the POPPI intervention

Objectives

• To standardise the proposed POPPI intervention.
• To develop an education package to train staff to deliver the POPPI intervention.
• To develop support tools and materials for staff and patients.

Oversight

The content of the POPPI intervention was informed, developed and refined by the lead adult critical care psychologist (DW), supported by two senior psychologists (CRB and JWei) and senior nurses (DS and JWel). An expert psychology advisory group (EPAG) was set up to oversee both the standardisation of the proposed intervention and the development of the education package and support tools.

The EPAG, chaired by Professor Daniel Freeman (a senior clinical psychologist and MRC Senior Clinical Fellow), met every 2 months and included expertise in clinical psychology, clinical education, critical care nursing and lived experience from former critical care patients. The former patients were chosen from a patient and family advisory group, set up in 2012 at University College London Hospitals NHS Foundation Trust (UCLH). Members brought clinical experience in psychosis and PTSD from University College London and from the Psychological Interventions Clinic for outpatients with Psychosis service, at the internationally renowned centre for training in CBT for psychosis at the Maudsley Hospital and Institute of Psychiatry, Psychology & Neuroscience at King’s College London, as well as experience in clinical and medical education, from Queen Mary University of London.

Standardisation of the intervention

Even though parts of the POPPI intervention had been delivered on a local level, it was vital to standardise the content of the proposed intervention to ensure that it could be delivered consistently across a number of different hospitals and by non-experts. To do this, we established whether or not any modification to the content of the proposed intervention was needed by reviewing stage one of the MRC framework (see Chapter 1, Background and rationale for details).45

Building on our previous work,16,47 we updated the evidence base on critical care-related psychological risk factors, outcomes and interventions. Two authors (DW and JWei) completed a systematic review of psychosocial interventions in critical care.51 We then completed step three (modelling process and outcomes), which the clinical research team had begun prior to the POPPI study.

This work confirmed that the key psychological outcomes should remain as PTSD and depression, as they were the most serious common psychological outcomes of critical care. As research in identifying modifiable critical care risk factors is more extensive for PTSD than for depression, we confirmed that the target of the intervention should remain as reducing the development of PTSD symptoms, which would be chosen as the primary outcome of the cluster RCT (if deemed feasible).

Creating a therapeutic environment in critical care

The aim of the first element of the POPPI intervention was to make all staff aware of the psychological distress endured by many critical care patients and to help staff learn ways to reduce stress in the environment and improve communication with distressed and fearful patients. When standardising the content of this element, the following key aspects were deemed to be required:

• Increasing awareness and understanding by staff of acute stress and poor psychological outcomes experienced by critical care patients.
• Identifying and reducing stressors in the critical care unit such as loud noise, unnatural light, pain, sleep deprivation and psychoactive drug effects.
• Improving communication between staff, families and distressed patients, particularly those who are delirious or experiencing hallucinations and/or delusions.
• Promoting a sense of hope and optimism during the psychological and physical recovery period.

Three stress support sessions for patients identified as acutely stressed

Building on the existing evidence and drawing on theory and techniques from CBT for psychosis and PTSD, the second element of the POPPI intervention was designed to be three, one-to-one, stress support sessions delivered to high-risk (acutely stressed) patients in hospital by a specially trained, self-selected, critical care nurse (‘POPPI nurse’). Acute stress was detected if a patient scored ≥ 7 on the Intensive care Psychological Assessment Tool (IPAT), previously developed and validated at UCLH.52 The three sessions included techniques adapted from CBT that were deemed appropriate for patients early in recovery, such as emotional expression, normalisation, cognitive reappraisal, psychoeducation and ‘homework’ tasks. Exposure to traumatic memories (one element of trauma-focused CBT) was not included as it was deemed inappropriate; for example, during the stress support sessions, patients are encouraged to express their thoughts and feelings about their critical care experiences if they wish, but not to undertake ‘reliving’ of their critical care stay, particularly as their trauma may be continuing.

It was planned that each session would last ≈30 minutes and that all three sessions would be delivered within a week (for the pragmatic reason that many patients might be discharged from hospital around that time) by the same trained POPPI nurse. Because of the nature of the sessions, they would start when the patient was awake and alert, either in the critical care unit or following discharge to the hospital ward.

The main aim of the stress support sessions was for nurses to develop a trusting relationship with patients, so patients could discuss concerns that they might feel embarrassed or worried about communicating, and to reduce emotional distress. The objectives included establishing a collaborative relationship focused on reducing distress; managing patient concerns, including hallucinations and delusions; psychological education (psychoeducation) to reduce distressing interpretations of unusual experiences, reduce stigma and encourage open communication; and provision of active coping strategies.48 Each session had five component parts. Patients were also asked to rate their stress levels on a ‘stress thermometer’ (a simple tool commonly used by psychotherapists to rate stress levels during therapy on a scale of 0–10) at the beginning and end of each session, to help nurses monitor how patients were responding as the sessions progressed.

Under the guidance of the lead adult critical care psychologist (DW) and supervision from the EPAG, the content of this element was standardised by two senior critical care nurses (DS and JWel) modelling the process of the stress support sessions with patients, after receiving training in delivering the sessions and close support from the health psychologist (DW) and a clinical psychologist from the EPAG. This step was important to ensure that the stress support sessions could be delivered to patients by specially trained non-experts such as experienced critical care nurses. Testing and revision of the elements of the stress support sessions continued prior to confirmation of the final content and process.

Relaxation and recovery programme for patients identified as acutely stressed

The third element of the POPPI intervention was a relaxation and recovery programme for high-risk (acutely stressed) patients. The programme was split into two parts. The first, starting within the first stress support session and to be used during the patient’s hospital stay, was designed to:

• provide meaningful activity and distraction
• help people practise new coping strategies to reduce stress and improve sleep
• learn from other patients’ experiences, between and following the stress support sessions.

Content was aimed at patients receiving the stress support sessions, who were to be given access to calming classical and ambient music; relaxation, breathing and visualisation exercises including ‘the safe place’ exercise; meditation exercises; nature sounds and videos; and patient recovery stories.

The second part focused on providing patients with information on making a good psychological recovery after a critical care stay and building on the support patients received during the stress support sessions, focusing on well-being and coping strategies. Patients would be given information about what to expect in the early days (e.g. leaving critical care, returning home, emotions after critical care, relationships), tips for psychological well-being, advice on coping with difficulties (e.g. worries, panic, low mood, memories), information on sources of psychological support, further information for family and friends and a personal action plan to promote well-being and recovery.

Development of the education package

Creating an education package to train critical care staff to deliver each element of the POPPI intervention was a major focus of phase one of the POPPI study. We adopted a ‘blended-learning’ approach, combining online training (e-learning) and face-to-face teaching. Interactive and engaging online training courses are recommended by educationalists for the provision of knowledge to a large number of staff, whereas face-to-face training is suitable for adults acquiring new skills by practising and receiving feedback.53 The education package was created by the clinical research team with support from the medical educationalist and other members of the EPAG, with specialist support from an online training designer and a medical film-maker from UCLH.

Creating a therapeutic environment in critical care

With guidance from the EPAG, it was decided that the most efficient way to ensure that the key learning aspects of this element reached as many of the critical care staff as possible was to create the POPPI online training course (titled ‘Improving communication and psychological care in the ICU’). The course was co-designed with experts to give a balance of concise, readable text with graphics and other visual or audio aids. The online training course was divided into four sections (see Standardisation of the intervention) with test-yourself questions at the end of each section (with informative feedback). Videos formed a key part of the course and included former patients talking about their experiences of critical care and nurses modelling good communication techniques with simulated patients. There was an assessment at the end of the training; on passing (i.e. a score of ≥ 80%), staff received certificates.

Three stress support sessions for patients identified as acutely stressed

To enable training to be conducted for three, self-selected, ‘POPPI’ nurses from multiple sites simultaneously, we created a central, face-to-face, 3-day training course. This course was devised under the guidance of the medical educationalist on the EPAG, with a major focus on delivery of the stress support sessions and the relaxation and recovery programme. In addition to the stress support sessions, key psychological principles underlying the intervention were taught and all three elements of the intervention were covered extensively during the 3-day training course.

Owing to the complexity of delivery of the stress support sessions, we decided it was necessary to spend a significant amount of available time devoted to skills practice in delivering the sessions. This practice would involve the training team (a psychologist, nurses and patient representatives) observing trainees delivering the sessions and offering feedback. We decided to have two patient representatives (former critical care patients) talking about their experiences of critical care each day; use games and exercises to enhance learning; and show and analyse a video of a sample stress support session delivered by a clinical psychologist specialist in psychosis.

We also designed the course to educate the POPPI nurses in their wider role in their units, including encouraging staff to undertake the online training and create and promote a therapeutic environment in the critical care unit; providing bedside teaching; and overseeing delivery of the whole intervention.

Finally, we planned an additional training day of feedback and assessment, aimed at supporting the trained POPPI nurses once they had delivered sessions to at least one patient. The day would include a focus group with the nurses on their experience of delivering all three elements of the intervention, and a competency assessment, in which each nurse delivered the second stress support session to a simulated patient (actor), observed by two trainers who completed an assessment checklist. Nurses would be required to pass the assessment. Anyone not passing the assessment would receive further training prior to sign-off of competency.

Debriefing and support for the POPPI nurses

A clinical supervision structure with one of the trainers (psychologist or senior nurse) was set up to allow regular ‘debriefing and support’ telephone calls. The first debriefing and support call was aimed to be made during or soon after the three stress support session nurses delivered to their first patients. Subsequent calls would be scheduled every 2 months, or at nurses’ request. The focus of these calls would be on enhancing nurses’ skills and discussing patient cases. E-mails could be exchanged between nurses and trainers about issues arising from stress support sessions at any time.

Relaxation and recovery programme for patients identified as acutely stressed

As the third element, the relaxation and recovery programme to reduce stress and improve sleep, is introduced to patients by POPPI nurses during the stress support sessions, we planned that education for element three would take place during the 3-day training course. This was to cover how to use the relaxation and recovery programme, theories of relaxation and mindfulness, and creating a patient action plan.

Development of support tools and materials

Creating a therapeutic environment in critical care

Materials to aid and encourage completion of the online training course were produced. Flyers, cards and posters advertising the online training were created to be displayed and left in communal staff areas.

Three stress support sessions for patients identified as acutely stressed

Associated training materials were developed for the POPPI nurses, including an intervention manual, a set of slides for the 3-day training course and a training folder. All were designed for readability and clarity, with short sections and clear signposting. All materials were designed using the same palette of fonts and colours, and included photographs, graphics and colourful diagrams. The writing of the stress support session manual was led by the lead adult critical care health psychologist (DW) with input and guidance from clinical psychologists and senior nurses, under the supervision of the EPAG. The manual comprised 32 pages, with sections on the POPPI nurse role; creating a therapeutic environment; screening with the IPAT; the relaxation and recovery programme; background and introduction to the stress support sessions; a two-page summary and one-page diagram of each session; and appendices of notes, scripts, language and examples to help nurses deliver the stress support sessions.

The manual was designed to be given to the POPPI nurses on the 3-day training course along with a training folder consisting of course hand-outs, games and exercises to practise stress support skills such as ‘guided discovery’ and ‘psychological education’, example patient scenarios for the skills practice sessions, laminated stress thermometers, summaries of each stress support session, and structured reflective note sheets for the nurses.

Relaxation and recovery programme for patients identified as acutely stressed

To give patients access to the relaxation and recovery programme, we developed an application (hereafter referred to as an app), which was loaded onto a tablet computer for use in hospital between stress support sessions, and a digital versatile disc (DVD) and patient booklet to use following the sessions and at home after hospital discharge.

The functionality of the app was developed by a web designer from UCLH, working closely with two psychologists who devised and procured the content. It had a green nature-scene background and large coloured buttons for patients to use for easy navigation between different sections. App contents included a ‘safe-place’ visualisation and relaxation exercise, muscle and breathing relaxation exercises; a body scan and other mindfulness meditations; relaxing classical music from Bach to Vivaldi and calming, modern ambient music; and restful nature sounds and videos. The app also included a section of former critical care patients’ recovery stories, to help to normalise emotional reactions and unusual psychological experiences in critical care, and to encourage hope and optimism for recovery. There were five stories from patients of differing age, sex and ethnicity, illustrating a range of critical care experiences. These were edited from patient interviews conducted by a psychologist and filmed by the medical film-maker.

The DVD included a shorter selection of relaxation exercises and music from the app, and longer versions of the patient recovery stories, assuming longer concentration spans as patients get closer to hospital discharge or go home.

The Getting Well, Staying Well patient booklet was developed to provide patients with useful information on making a good psychological recovery after a critical care stay. The booklet was designed to build on the support patients had already received during the stress support sessions. Getting Well, Staying Well was designed as a readable guide focusing on psychological well-being and positive coping strategies to help patients better deal with the challenges of recovery.

Research has shown the effectiveness of CBT-based self-help books for common mental health problems and also found that guided self-help, in which a professional is involved in supporting and offering guidance on how to use the self-help materials, makes self-help more effective than the provision of information alone. In line with this, the patient booklet involved guidance from the POPPI nurses during the stress support sessions on the use of the booklet and DVD.

Improving Access to Psychological Therapies guidelines54 recommend that self-help resources should follow three principles: (1) communicate a normalising recovery-focused message, (2) help patients understand their difficulties in a timely and understandable way and (3) facilitate knowledge and acquisition of evidence-based interventions to enhance self-efficacy and promote self-management.

The Getting Well, Staying Well booklet has the following contents:

• personal stay-well plan
• information about what to expect after critical care in the early days
• seven tips for psychological well-being
• advice on coping with difficulties (e.g. worries, panic, low mood, memories)
• further information on sources of psychological support
• information about the relaxation and recovery programme (DVD)
• information for family and friends.

The personal stay-well plan would be used to address the potential challenges ahead and create an individual psychological recovery plan based on advice and information in the rest of the booklet.

Conclusion

Building on previous work by this team, the proposed intervention was standardised to allow consistent delivery across different hospitals, by non-experts. To facilitate this, an education package and associated support tools were developed (Table 1). The key assumptions and theory underpinning the POPPI intervention are diagrammatically represented in Figure 1. The intervention and education package were ready for testing the feasibility of delivery and acceptability.

FIGURE 1 The POPPI intervention logic model. HRQoL, health-related quality of life. (Figure not reproduced here; see the original article.)