Presence of psychologists in the French intensive care units: a gap between requirements and practice

Experiencing a stay in an intensive care unit (ICU) can be traumatic for critically ill patients who are exposed to a technical environment and the fear of dying. At least one third of the survivors develop psychological disorder, including anxiety, depression or post-traumatic stress disorder [1]. There is also evidence that the relatives can suffer from emotional distress during and after the ICU stay of their loved one, leading to the so-called post-intensive care syndrome-family [2]. The burden is also considerable for relatives of patients who die in ICU, leading potentially to a complicated bereavement.

Patient- and family-cantered care in ICU is a holistic model of health care recognizing the importance of a humanized environment to improve recovery, in which psychologists may play a key role [3]. In 2021, the French government asked the scientific societies to draw up an overview of the presence of psychologists in ICUs. A national decree was also published in April 26th, 2022, recommanding the presence of psychologists in French ICUs (https://www.legifrance.gouv.fr/eli/decret/2022/4/26/SSAH2206984D/jo/texte). However, how this decree is translated into practice is unknown. (https://igas.gouv.fr/L-offre-de-soins-critiques-reponse-au-besoin-courant-et-aux-situations). In this context, the aim of the present study was to describe the presence of psychologists in French ICUs and to identify the potential obstacles to their effective integration in ICU teams.

A questionnaire was designed by the Patients and Relatives Working Group of the French Society of Intensive Care Medicine (SRLF). The first question was “Does your ICU team include a dedicated psychologist caring for patients and relatives?”. In case of positive answer, the next question was “What proportion of his working time is dedicated to ICU?”. In case of negative answer, two further questions were asked: “Do you have access to psychologists from other departments in your hospital?” and “What are the main barriers preventing the inclusion of a psychologist in your ICU team?”. The following barriers were explored: 1) no financial resources, 2) hospital management decision, 3) no interest.

The survey was conducted between January and December 2023. A total of 322 ICUs were identified, representing approximately 90% of all the ICUs in the country. The medical director and/or the head nurse of each ICU were contacted by telephone or email. Twenty ICUs did not respond (response rate: 302/322, 97%). The characteristics of the participating ICUs are described in Table 1. The presence of a dedicated psychologist was confirmed in half of the participating ICUs (156/302, 51.6%), committing 0.5 (0.3–0.75) working time equivalent (WTE) to this function. In these ICUs the psychologist-to-bed ratio was 1/40. ICUs located in university hospitals were more likely to have a psychologist (79/109, 72%) than the other ICUs (77/193, 39%) (p < 0.001). Among the 146 ICUs without dedicated psychologist, 115 (79%) had access to psychologists from other departments in their hospitals, and 8 (5%) have no access to any psychologists at all. The main barriers precluding the presence of a psychologist in the 42/146 (29%) responding ICUs were: no financial resources (25, 60%), refusal of the hospital management (17, 40%), not interested (9, 21%), interested but not a priority (6,14%) and interested but no candidate (4, 10%) (Fig. 1).

Table 1 Characteristics of the participating ICUs

Fig. 1

Infographic showing the main results of the survey

This survey shows that despite legal obligation, a number of ICUs in France do not benefit from the presence of a dedicated psychologist. The main barrier is the lack of financial ressources and the refusal of the hospital management.

Evidence supports the positive impact of psychological interventions during the ICU stay on long-term psychological disorders in critically ill patients and families [4]. However, the role of ICU psychologists extends well beyond interventions for patients and families. Working with ICU staff members, psychologists can help them to process the emotional burden of their work, can train staff in best psychological care for patients and relatives, can provide skills of communication with patients, and can support the implementation of ICU humanization strategies. Altogether, they contribute to ICU staff wellbeing, that is known to be closely associated to quality of care and medical outcomes. These benefits at the hospital system level could help arguing against the described financial barriers.

All these areas of input justify a significant working time in the ICU [5]. Compared to the recommendations of 1 WTE psychologist for 20 ICU beds in United Kingdom (https://ics.ac.uk/resource/integrated-practitioner-psychologists-guidance.html), the described availability of psychologists in the French ICUs may result in insufficiently met needs in terms of patient support and teams. Alternative models to ICU dedicated psychologists exist in daily practice, such as resource mutualisation with other hospital departments or regional ICUs. However, their efficiencies have not been investigated.

The present survey format did not allow a comprehensive analysis of the facilitators and barriers to psychologist presence in ICU. The findings, however, highlight the gap between national recommandations and practices. Integration of psychologists in each ICU can help enhancing patients and family members ICU experience and well being at work, and can thus lessen the burden of critical care on the public health system.