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This is a pre-publication version of the following article: Atkins, E. & Syed-Sabir, H. (2022). PIE in PICU
and NICU: Developing Psychologically Informed Environments. Clinical Psychology Forum, 359, 9-19
PIE in PICU and NICU: Developing Psychologically Informed Environments
Dr Ellie Atkins
a
Dr Hena Syed-Sabir
b
a
Consultant Clinical Psychologist, London Neonatal Operational Delivery Network
a
Clinical Psychologist, Paediatric Intensive Care, Birmingham Children’s Hospital
Corresponding author:
E.Akins4@nhs.net
Summary
This paper sets out how the Psychologically Informed Environments (PIE) model, which originated in
the homelessness sector, can be applied to the complex medical environments of Neonatal and
Paediatric Intensive Care (P/NICU). Whilst there are key differences between NICUs and PICUs, there
exist so many commonalities, most notably the similarity of parent and staff experiences and the
coexisting medical, psychological and developmental needs of babies and children. PIE provides a
whole systems approach to improving psychological wellbeing in all those in the environment:
babies, children, parents, families and staff. The paper explores how PIE methodology could be
applied to P/NICUs; offering examples grounded in practice; and describing how PIE can meet the
fundamental needs of babies and children, parents and staff and has the potential to prevent the
challenging environment having a negative impact on those who are exposed to it.
Introduction
Intensive care units (ICUs) are demanding environments, caring for very sick patients. NICUs care for
the most seriously ill and very premature infants. Infants resuscitated at birth from 22 weeks are now
present on the NICU, alongside babies born at all gestations beyond this, and their term-born peers
who have serious and life-threatening illnesses. PICUs cater for the most seriously ill babies and
children and both units provide a high level of observation and intensive medical care.
In Neonates and Paediatrics, there is added complexity in ICU as the patient (baby or child) also comes
with parent(s) or carer(s) alongside them and their concerns and needs must also be attended to.
Admission to NICU and PICU can be significantly traumatising for families just as it can be for babies
and children (Grunberg, 2018; Bry and Wigert, 2019; Johnson & Marlow, 2011; Atkins et al, 2012).
Higher rates of mental health difficulties meeting diagnostic criteria are seen in parents who have
infants in neonatal care when compared to the general perinatal population (Feeley et al., 2011;
Lefkowitz et al., 2010).
Staff working in these environments are also at risk with 40% of N/PICU staff found to be experiencing
burnout, moral injury or post traumatic stress symptoms or a combination of these difficulties (Colville
et al, 2017, Jones et al, 2020). Therefore, there is an argument for providing an intervention which
attends to the needs of all of these groups, and an imperative to offer it to all patients, families and
staff with the aim of better supporting them as they experience the N/PICU environment (Colville et
al, 2021).
Paediatric intensive care units (PICUs) and Neonatal Intensive care units (NICUs) do sometimes have
access to psychological support, but this is often limited and therefore offered to those most in
distress. Often the psychosocial needs of children, families and staff are missed. However, there are
opportunities to intervene at the universal level, developing a Psychologically Informed Environment
(PIE) from which all babies, children, families and staff can benefit. This would involve employing a
‘spend to save’ mentality, where the cost of funding psychological support for PIE development pays
dividends in terms of savings across the lifespan of the baby/child, family and staff members.
What is a PIE?
A Psychologically informed environment “is one that takes into account the psychological make up –
the thinking, emotions, personalities and past experience – of its participants in the way that it
operates’ (Johnson, 2012). It’s an approach that considers both users of a service and the
psychological needs of staff ‘developing skills and knowledge, increasing motivation, job satisfaction
and resilience’ (Westminster CC, 2015). Developing a Psychologically informed environment is a
journey, not a destination to be achieved and then ticked off. The work involves embedding ideas
which in turn requires engagement from all levels of department, senior management and across
professional disciplines. In a N/PICU there is added complexity that mental health and wellbeing
professionals are working within acute environments and a broadly medical model. This can present
both challenges and opportunities.
PIE was first championed in homelessness settings and there are clear parallels between the two
settings. Both have highly transient populations with some long-stayers, both have client groups
experiencing high levels of distress and who have had significant exposure to trauma. Both are
staffed by dedicated but often overworked staff members who need to regulate and manage both
their own and others’ emotion and behaviour, whilst meet the needs of clients in the complex
environments they find themselves. PIE aims to be non-pathologising and recognises that distress or
other strong emotions are a response to challenging and often traumatic circumstances.
There have been many initiatives happening in units, at a local, regional and national level to
improve the experience for babies, children and families. These include trauma informed care
(Charan Ashana, Lewis & Lee Hart, 2020), Family integrated care (FiCare; e.g O’Brien et al, 2018) the
Bliss Charter (Bliss, 2020) and the Baby friendly initiative (UNICEF, 2017). These are all excellent
models and support the development of good practice. However, on both PICUs and NICUs, there is
a dearth of evidence that draws together the multifactorial complexities within Intensive care and
offers a framework to both develop practice and respond to challenges. The PIE model includes all
the TIC elements, and the aims of FiCare, BFI and the Bliss charter. It also goes further, enabling the
exploration of the nuances of ‘trauma’ in a unit dealing with both psychological and physical trauma
every day, with almost every patient and family. And beyond this, PIE is a wider approach allowing a
more holistic viewpoint to be assumed, seeing the unit, the family, the patient and the staff as in a
relationship that can be improved. It moves beyond a linear conversation which might alienate those
who do not feel they are experiencing ‘trauma’ to think broadly and systemically providing tools to
enable progress in a number of areas.
To create PIEs in P/NICU is therefore a non-diagnostic, non pathologising, and system-wide
preventative health approach, aiming to reduce distress and enhance the lived experience of all who
are involved in units. Prevention has been conceptualised as including a number of factors specific
factors (APA 2014), which when related to P/NICU and PIE can:
• reduce the impact of intensive care admissions for patients and families
• strengthen knowledge and behaviours in staff and patients/families that promote
psychological well-being
• promote institutional, community, and government policies that mitigate against negative
outcomes of admissions
• further explore and develop the evidence base around physical, social, and emotional
well-being for patients, families and the teams looking after them
On a N/PICU, Psychologically informed environment is functioning well if all levels of complexity are
included in the framework: the sickest patients; the most distressed or challenging parents; the full
range of staff from those engaged and motivated to those who are initially sceptical or resistant.
Key messages:
- PIE is principle-based framework with shared language and approaches to communicate,
implement, and enhance practice
- There is no single PIE model or PIE ‘checklist’ to implement, rather organisations need to
consider elements and implement and tailor to their place of work
- PIE offers teams the opportunities to try things out and gather evidence of what works
Why do we need PIE on P/NICU?
There is a huge potential for distress and trauma within the N/PICU environments and therefore a
model which helps us to understand the behaviour and emotional experiences of staff and families is
vital. PIE considers the whole environment, rather than just one aspect like the skilling up of families,
the demeanour of staff or distress of carers. PIE allows space to reflect holistically and to effect
meaningful and lasting change.
How to implement PIE on P/NICUs
The PIE model has 5 key elements. These are discussed in turn with suggestions for how units could
begin to implement the model in practice.
Key element 1: Relationships
As a first building block, PIE emphasises the importance of relationships as the principal tool for
change. On N/PICU units this involves the added complexity of a huge multidisciplinary team caring
for the child including nursing care (which changes shift every 12 hours), medical care, allied health
professionals like Physiotherapists, Speech and Language therapists and dieticians and Psychological
professionals such as Clinical Psychologists and/or psychotherapists. There are also ward clerks,
housekeeping, domestic/cleaners, pharmacists, porters, imaging staff and many other professionals.
The child’s bedside can often become a circus of different professionals talking with the family and
treating the child. In this context the building of strong and working relationships is both challenging
and absolutely vital.
Relationships extend beyond the parent-staff axis to include peer relationships between members of
staff and relationships between parents and carers.
Figure one: One facet of the complexity of relationships on the N/PICU
AHPs = Allied health professionals including but not limited to Physiotherapy, occupational therapy,
dietetics, speech and language therapists and pharmacists.
In Fig. one, the impact of positive peer relationships is harnessed for the wellbeing of all. The use of
peer support workers on units, including parents who have had experiences of the P/NICU
AHPs and
Psychology
Baby or child
Nursing, medical
and AHP staff
parent or carer
Medical
staff
Nursing
staff
Baby or child
Nursing, medical
and AHP staff parent or carer
Medical
staff
Nursing
staff
environment and been discharged home, allows the sharing of unique and valuable perspectives to
their counterparts still in hospital. Staff reflective practice groups and in/outpatient parent groups,
all provide spaces for parents/staff to talk about their experiences and listen to the experiences of
others. Such groups can be important for normalising experiences of the busy and difficult intensive
care environment (Thomas-Unsworth et al, 2021) and provide opportunities for peers to problem
solve together. Relationships are the cornerstone of family integrated care (O’Brien et al, 2018)
where parents are seen as partners in care and they work together with staff for the good of their
baby.
In the PIE model there is a clear emphasis on involvement and inclusion in the PIE activities of a unit,
and finding ways to include families or staff where there is complexity is a part of this. On N/PICUs
this might involve extending the offer of parent groups to those parents who are more difficult to
engage, (perhaps because of their own complex early histories or because they speak different
languages) or very distressed by the admission or their experiences. Other key inclusive relationships
will be built by consulting with staff and families about what are the best initiatives to develop
practice or engender change. In this way those who are distressed, disengaged or are actively critical
of the unit or the model are not excluded. These relationships should not always be formal or
planned. The PIE model also encourages the opportunities for informal and impromptu staff/family
interactions. In ward settings the roving ‘tea trolley’ can provide this opportunity, this has been
trialled at Birmingham Children’s hospital PICU, facilitated by the lead nursing team and psychologist
with families and staff having an opportunity for another interaction other than the often busy and
often fraught ward rounds.
Psychological professionals working on N/PICUs already have relationships as a key tenet of their
practice and will be primed to both model and train in this area. They bring their training and
experience in a range of therapeutic approaches, such as compassion focused therapy to bear in
these situations. They are also able to assess, often ‘live’ during an initial conversation, where
relationship building should start and what are the key priorities for the Psychologically informed
care of someone who is distressed or traumatised.
The focus on the relationship is not a new idea, and much has been written about this, particularly in
healthcare. That relationships are in the PIE model as the first principle reflects the vital role of these
relationships in caring for very sick babies and children, and it is clear that where this goes wrong
lives can be lost. For example, Patricia Ockenden, in her review of maternity and neonatal services,
highlighted the vital role of good communication with families and compassionate care towards
babies and their families (Ockenden, 2022) but also noted that families often felt ‘unheard’ or
overlooked (Ockenden 2020). She also noted relationships between services are just as key as those
within services: “Neonatal care is most effective when delivered in close partnership with other
services….when reviewing individual cases we found evidence of effective joint working (p140,
Ockenden, 2022). She has recommended that Maternity and Neonatal staff train together to
develop positive relationships resulting in better care to families (ibid).
PIE also champions the concept of ‘elastic tolerance’ (Breedvelt, 2016) which, in the context of
homelessness, considered how to deal with issues which might normally result in warning or eviction
from a setting. In N/PICU this same principle can be applied to a number of difficult situations.
Relationships become key when there are challenging circumstances, such as delivering a
devastating diagnosis to parents, seeking a court order to withdraw care, discussions about
palliation or the need to discuss inappropriate behaviour with a parent or member of staff. A
knowledge of the key elements of good relationships should therefore be included in the N/PICU
induction or speciality training of all staff (no matter which profession) to support their ability to
converse with parents and young people on these highly emotive topics, sometimes having not
known the family for very long.
Key element 2: staff support and training
The case for staff support in N/PICU is well established (e.g. Vincent et al., 2019). Further funding is
required in many cases to make this a reality. Often, and especially since COVID, staff support
services across trusts are adept at providing both generic and targeted interventions. However the
nature of the N/PICU environment means that embedded staff support is vital.
A practitioner (such as a Clinical Psychologist) embedded on a N/PICU with a specific mandate for
staff support can enable a unit to achieve the PIE principles under this key element. This includes
reflecting with the service on the working practices and supporting continuous improvement. They
have the ability to develop staff competencies and confidence in working with distress and complex
trauma and to think about the impact of the work on them, including thinking about the post
traumatic stress, moral injury and burnout they may be facing in the course of their work (Thomas-
Unsworth et al, 2021). The overall aim of this is to ensure that all staff share an understanding of
complex trauma and challenging behaviour and staff feel confident to work flexibility and creatively
and to respond to issues or challenges, including for their own mental health. On the N/PICU this
involves engaging the whole staff team (often it is difficult to ‘reach’ beyond nursing staff) which
requires creativity.
Training is key in motivating and retaining staff and building residence into the system. The overall
aim of training would be to embed PIE principles throughout the unit, giving staff a sense of
accomplishment improves as they see changes in unit, team and family functioning. Outcome
measures for this include turnover and absentee rates which are routinely gathered as part of
workforce mapping. A unit developing a PIE model would hope to see these reduce over time (.
D’Urso, et al 2019)
Figure 2: Universal preventative care for staff and beyond.
Developed by Clare Barker-Ellis & Hena Syed-Sabir (adapted from Kazak, 2006)
The overall aim would be movement between a ‘reactive’ system and a ‘reflexive’ system where
there are calm spaces to reflect on decision-making, team cohesion, team and individual efficacy
(Hobfoll et al, 2007). Opportunities for safe psychological debriefing within NICU (Archibald &
O’Curry, 2020) and PICU (Butchera et al, 2022) alongside reflective listening sessions such as ‘Spaces
for listening’ or Compassion circles/Care Space (Clark et al., 2021) facilitated by the psychologist,
allows movement away from an expectation that trauma is ‘part of job’ to experience that needs
active management.
PICU, KIDS and NTS Psychology:
Staff Service Model
Specialist
Clinical
Psychology Care
Targeted
Well-being Support
Framework
Universal
Education, Resources
and Culture
•1:1 Clinical Psychology staff support
(telephone, video, face to face)
•Range of therapeutic models
•Consultation on working with Complex
Cases and Families
•Psychological Clinical Supervision
•Liaison and signposting for mental
health support and other services
•Teaching and Training
•Induction, transition points, away days
•Intranet and Newsletters
•Psychoeducation
•Social Media (facebook, twitter)
•Research (service evaluations, audits)
•Specialist interest groups
•Developing and sharing resources
•Debriefs/Pre-briefs/Support Sessions
•Follow-up Support sessions
•Listening Sessions
•Staff well-being meetings
•Supporting staff safety processes
•Extended Stay input
•Reflective Rounds
•Care Space Model sessions
Key element 3: The physical environment and processes
This element of the PIE model is, at first sight, challenging to institute in a busy P/NICU. The model
suggests that clients are welcomed into a non-institutional safe space that facilitates interaction
between staff, patients and families. The P/NICU environments are highly medicalised, with a great
deal of complex equipment and an emphasis on infection control, with wipe-clean surfaces and
handwashing stations. Whilst these efforts are all focused on the safety and care of the infant, it can
be an overwhelming environment for families to come into. There are also challenges as the P/NICU
environments serve simultaneously as an office for staff and a bedroom for children (McDonald et
al., 2012). Parents must walk a fine line between wanting to make the environment personal and
warm and not interfering with the primary function to save their child’s life and treat their medical
conditions.
Despite these challenges P/NICU environments can also be supportive and facilitative for all who use
them. Parent and family spaces can be made warm and welcoming both physically with furniture
and décor, and through policies which provide access when needed and recognise the needs of
parents to rest, refuel and communicate. Staff can also ensure that interaction within the
environment is easy, thinking about where they position themselves when they are engaging
families (behind a desk or alongside parents at the bedside). Managers can promote health and
wellbeing through ensuring breaks are always protected, the staff spaces are restful not an
extension of the ward and that there is a culture of health and wellbeing communicated through all
meetings and ward rounds.
Policies and procedures can also support the wider psychologically informed environment. FiCare,
which is gaining much support in NICUs encourages parents to attend ward rounds, attempting to
provide some choice and control for them over the admission, which can often feel alarming
(O’Brien et al, 2018.) It also allows staff to listen to the real and valid concerns of parents and
families and take seriously any issues they raise, promoting a sense of physical and emotional safety
both for patients, families. The same must be offered to staff through robust procedures where they
can raise both ideas and concerns and speak without fear of reprimand. Providing a range of
communication opportunities (for parents and staff) allows them to choose how and when they
engage.
Organisational values, including a commitment to creating a PIE should be explicit to all who use or
visit the units. P/NICUs would do well to look through the eyes of a baby/child and then through the
eyes of a parent or family member and a staff member, carrying out a walk-through of the building
and the unit, experiencing the admission and induction process and the ongoing experience of being
on the unit. Such walk-throughs would allow those keen to implement PIE to reflect on all elements
of the physical environment and process, looking at routines, structures of the day, the way cares
are clustered, how the sleep/wake cycles are managed, how parents are given space to engage with
their babies or children and how families and staff are provided good quality rest facilities and
opportunities to hydrate, fuel and rest.
Key experiences and needs including pain management, opportunities for play and development and
for soothing and holding, places to breastfeed and express milk, sensory-attuned settings and
managing end of life care also need to be planned and developed within the PIE framework
(Dorenbos et al, 2012). Figure two highlights the kinds of interventions which can be offered to
families. In particular these key experiences and needs represent the universal level of care which
aims to be supportive for families and preventative, reducing the overall negative impact of the
admission.
Figure 3: Universal care for all as a preventative intervention aimed at supporting all families with a
P/NICU admission. Developed by Hena Syed-Sabir, 2022 (based on Kazak, 2006)
Key element 4: A psychological framework
This key element requires that staff can describe the needs of their patients and families in
psychological terms. This requires significant staff training, including simulation training, to enable
staff (at all levels) to see unmet psychological needs where previously they would have labelled child
and/or families as ‘challenging’ and talked about problem behaviours or mental health issues.
Further, staff need time to reflect together in order to develop an understanding of their own, and
families’ and children/babies’ psychological needs, and the relationship between the two in the work
that they do. Managers can do the same for the needs of their staff. Clinical Psychologists with skills
in formulation have a key role to play in the development of these skills. There is also a need for this
person to model and develop the appropriate containment and emotional holding required for staff
to staff manage and reflect on their own thoughts, emotions and behaviour and those of their
patients and families.
The PIE model sees behaviour as communication and the environment can be adapted to manage
this. Often in a highly pressurised environment it can be hard to maintain respectful, thoughtful and
non-threatening communication. Parent and carers can have high levels of expressed emotion which
can be interpreted by staff groups to be ‘challenging and difficult to manage’. Staff behaviour can
change by staff becoming ‘burnt out’ which includes: emotionally exhausted by the work,
depersonalisation and lack of personal accomplishment. With long shifts and differing shift patterns,
staff can experience little or no support from colleagues which exacerbates their experiences (Costa
& Moss, 2018). PIE includes a focus on relationships, in this instance, between staff by offering
reflective spaces, psychological debriefs and implementing a model of peer support (Thomas-
Unsworth et al, 2021) and challenging threat behaviours which may emerge from staff groups by
models such as ‘Civility Saves Lives’ co-founded by Chris Turner (Riskin et al, 2014).
Vital in developing a ‘psychological framework’ is that the service is a role model for the
environment it is trying to create, so service culture and support should be reflective, thoughtful and
compassionate. This requires the service to be well staffed, for staff presenting with challenges to be
thoughtfully responded to and including adequate psychological professionals with a remit to train
and support staff and families, modelling these skills to the whole staff team.
Key element 5: Evidence generating practice
Finally, in line with all effective practice, N/PICUs will need to collate and analyse outcomes in order
to identify what is working and feed into continuous learning and improved. Evidence of change can
also be used to demonstrate progress to all stakeholders including families and staff on the units.
Further this data would support other units to embrace PIE if they can show a positive difference.
This element highlights the need for embedded psychological support, provided by someone with a
sound research training who can design, gather and interrogate the evidence to make sense of what
is happening in the complex P/NICU environment.
Conclusion
P/NICUs are complex and highly emotionally charged environments. PIE is a holistic model which can
be integrated into the work of a unit, both using existing structures and policies and by developing
new pathways. The cornerstones of the model are relationship building and reflection, but to
succeed Psychologists and other practitioners need genuine and tangible backing from senior
managers and leaders as well as in-unit champions (or PIEoneers!) for development, monitoring,
reviewing. Like making a great pie, the model takes time to be implemented and there is a need to
do this in an inclusive and staged way, getting commitment from all staff. If done thoughtfully and
openly, PIEs have the potential to make a real, lasting and positive impact to the P/NICU
environment and the babies, children, families and staff who work or reside in them protecting them
during admission and post-discharge.
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