Barriers to Finding Psychology Postdoctoral Training Opportunities in Intensive Care Settings

Abstract

Purpose/Objective:

U.S. health organizations, including Division 22 of the American Psychological Association, the Society for Critical Care Medicine, and the American Thoracic Society advocate for psychological treatment that improves long-term outcomes in critical illness survivors. However, limited information exists with regard to psychology training opportunities in intensive care settings. We aim to identify and describe (a) existing psychology programs with training in intensive care settings and (b) barriers to finding these training opportunities.

Research Method/Design:

Using aspects of the Arksey and O’Malley Framework and Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews reporting checklist as guides, two independent reviewers searched the Association of Psychology Postdoctoral and Internship Centers (APPIC) Directory and Universal Psychology Postdoctoral Directory (UPPD) to identify programs with training experiences in intensive care settings.

Results:

Searching the APPIC Directory did not reliably or accurately identify training opportunities in intensive care settings. Thus, only programs identified in the more reliable UPPD search were considered for inclusion. After duplicates were removed, searches using the UPPD yielded 31 programs for review. Of those, 22 programs met inclusion, offering heterogeneous training in intensive care settings.

Conclusions/Implications:

These results suggest few opportunities exist for psychology training in intensive care settings and available opportunities are difficult to identify using standard search methods. The identified challenges also emphasize the need for advanced search features for training opportunities within APPIC/UPPD and/or a list of programs offering these training opportunities. Our results highlight the importance of program descriptions that accurately and comprehensively reflect training opportunities—particularly relating to opportunities in intensive care settings.

More than 5.7 million individuals are admitted to intensive care¹ units (ICUs) in the United States annually and technological advances have increased the likelihood of survival (Barrett et al., 2011). Patients experience high rates of potentially modifiable sequelae of critical illness, including delirium, anxiety, acute stress disorder, hospital demoralization, sleep disturbance, and pain (Girard et al., 2018; Kamdar et al., 2012; Martorella, 2019; May et al., 2021; Wade et al., 2015). As a result of these experiences, survivors of critical illness often experience physical, cognitive, and psychological impairments that last for months or years after hospitalization. Taken together, these symptoms have been referred to as postintensive care syndrome (PICS; Needham et al., 2012). Acknowledging that survival is a necessary, but insufficient, outcome, many organizations, including the Society of Critical Care Medicine (SCCM), the American Thoracic Society (ATS), and the American Psychological Association’s Division 22 have emphasized the need to reduce psychological burden and improve outcomes for critical illness survivors (Elliott et al., 2014; Jackson & Jutte, 2016).

With the aim of improving long-term outcomes in critical illness survivors, integration of psychologists into intensive care settings may help address modifiable environmental and behavioral risk factors for PICS (Jackson & Jutte, 2016). Although rehabilitation psychology foundational principles and specialty competencies provide essential groundwork for practicing in intensive care settings, specialty training in critical care psychology is also needed to be a successful and effective team member (Beadman & Carraretto, 2023; Stucky et al., 2016). In our review of the literature, there are few guidelines or formal training standards around practice in hospital and ICU settings. Briefly, to acknowledge the increase in the diverse range of clinical services provided across healthcare settings, the Committee on Professional Practice and Standards has developed “Guidelines for Psychological Practice in Health Care Delivery Systems” (American Psychological Association, 2013). However, these guidelines do not specify practice in hospital contexts. Future consensus to create guidelines around core competencies and standards of practice specific to critical care is warranted. Although no guidelines currently exist for psychology practice in critical care, some of the knowledge and skills necessary to work as a psychologist in these settings include (a) understanding effects of life-saving procedures and medications on various domains of functioning, (b) evidence-based communication with patients on mechanical ventilation (Happ et al., 2010), (c) common neuropsychological presentations in critical care, and (d) understanding multiprofessional roles and team dynamics. Opportunities to train in intensive care settings and in critical care psychology may increase the number of psychologists available to practice in this setting.

Aims

The purpose of this report is to identify and describe (a) existing psychology predoctoral internship and postdoctoral residency programs that offer training in intensive care settings through common and recommended search strategies (i.e., Association of Psychology Postdoctoral and Internship Centers [APPIC] Directory, Universal Psychology Postdoctoral Directory [UPPD]; e.g., https://www.apa.org/gradpsych/2014/04/postdoc-search) and (b) the barriers to successfully finding these training opportunities.

Method

Study Design

To systematically search for training programs, our process was guided by the Arksey and O’Malley (2005) framework for conducting scoping reviews and adhered to the relevant aspects of the Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews checklist and reporting guideline (Tricco et al., 2018). The APPIC Directory and the UPPD were the two databases used to search for programs offering training experiences in intensive care settings.

The search was conducted by two independent reviewers (masked for review) in February 2022. Search terms were critical care, intensive care, ICU, trauma surgery, critically ill, and critical illness (online supplemental material section 1.1). Training programs were included if they explicitly stated training opportunities in an intensive care setting. Discrepancies in findings were discussed and resolved by reviewers using prespecified inclusion and exclusion criteria and, when necessary, final resolution was determined by Megan M. Hosey.

Transparency and Openness

All findings are based on the above inclusion/exclusion criteria. The directories utilized during searches are publicly available and can be found at appic.org.

Results

Using this search strategy, the APPIC directory did not accurately or effectively return useful results for predoctoral internship programs that included training in intensive care settings due to inefficient Boolean operators. For example, “intensive care unit” returned hundreds of programs containing the word “intensive,” “care,” and/or “unit” anywhere in the description (e.g., “United States” for “unit,” or “curriculum” for “ICU”). Thus, only programs identified through the more reliable UPPD search were considered for inclusion, and our search was subsequently limited to only psychology postdoctoral training programs. Searches using the UPPD yielded 31 programs for review (online supplemental material section 1.2). Of those, 22 programs met the inclusion criteria (Table 1), with 11 (50%) offering training in pediatric intensive care settings, seven (32%) in adult intensive care settings, and five (23%) in infant and families intensive care settings (e.g., neonatal intensive care unit [NICU]). These postdoctoral training programs identified a primary specialty focus in clinical health psychology (n = 16, 73%), clinical neuropsychology (n = 3, 14%), rehabilitation psychology (n = 2, 9%), and child and adolescent psychology (n = 2, 9%). Primary settings of identified programs included: children’s hospitals (n = 8, 36%), general hospitals (n = 7, 32%), medical schools (n = 6, 27%), Veteran’s Affairs Medical Centers (n = 1, 5%), and military hospitals (n = 1, 5%). Training opportunities in intensive care settings varied between programs, in relation to training emphasis (e.g., primary or secondary), training type (e.g., consultation service, neuropsychological assessment), and population focus (e.g., adult patient, child or infant patient, family, and team member).

Table 1.

Postdoctoral Programs With Training Opportunities in Intensive Care Settings in the United States (UPPD)

Program	Specialty	Setting	Population	Focus
AMITA Health, Hoffman Estates, Illinois	HP	General hospital	Pediatric	C/L PICU
Boston’s Children’s Hospital, Boston, Massachusetts	HP	Children’s hospital	Pediatric	Cardiac ICU
Children’s Hospital of the King’s Daughter, Norfolk, Virginia	CAP	Children’s hospital	Pediatric	C/L PICU
Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania	HP	Children’s hospital	Pediatric	Cardiac ICU
Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania	HP	Children’s hospital	Infant/family	Neonatal ICU
Gundersen Health System, La Crosse, Wisconsin	HP/RP	General hospital	Adult	Spinal cord injury
Gundersen Health System, La Crosse, Wisconsin	HP	General hospital	Pediatric	C/L NICU/PICU
Henry Ford Health System, Detroit, Michigan	HP	General hospital	Infant/family	Neonatal ICU
Hurley Medical Center, Flint, Michigana	RP/CN	General hospital	Adult	ICU
Jackson Health System, Miami, Florida	HP	Medical school	Adult	C/L MICU/SICU
Jackson Health System, Miami, Florida	HP	Children’s hospital/medical school	Pediatric	C/L PICU
Kaiser Permanente North Bay, Vallejo, California	HP	General hospital	Adult	Trauma Surgery
Nationwide Children’s Hospital, Columbus, Ohio	HP	Children’s hospital	Infant/family; pediatric	NICU/PICU
Nemours Children’s Health, Wilmington, Delaware	HP	Children’s hospital	Pediatric	CICU; NICU/PICU
Primary Children’s Hospital, Salt Lake City, Utah	HP	Children’s hospital	Pediatric	C/L CICU/NICU
SA Uniformed Services Health Center, San Antonio, Texas	HP	Military hospital	Pediatric	C/L PICU
Spaulding Rehabilitation Hospital, Charlestown, Massachusetts	CN	General hospital	Adult	NCCU (Research)
Stanford University, Stanford, California	CAP	Medical school	Infant/family	NICU
VA North Texas, Dallas, Texas	CN	Veteran’s affairs medical center	Adult	SICU
University of Colorado, Aurora, Colorado	HP	Medical school	Infant/family	NICU
University of Florida, Jacksonville, Florida	HP	Medical school	Adult	Trauma Surgery
University of Iowa, Iowa City, Iowa	CAP	Medical school	Pediatric	C/L NCCU

Note. C/L = consultation/liaison; CAP = child and adolescent psychology; CN = clinical neuropsychology; HP = health psychology; ICU = intensive care unit; CICU = cardiac ICU; MICU = medical ICU; NCCU = neuro-critical care unit; NICU = neonatal ICU; PICU = pediatric ICU; RP = rehabilitation psychology; SICU = surgical ICU; UPPD = universal psychology postdoctoral directory.

^aProgram added during a second search utilizing the “other emphasis” option in the Universal Psychology Postdoctoral Directory.

Discussion

Given the adverse long-term effects of critical illness and associated psychological sequelae, many organizations are advocating for improved access to psychological care in intensive care settings (Elliott et al., 2014; Jackson & Jutte, 2016). Including specialty-trained psychologists in these settings may enhance the management of cognitive, emotional, and behavioral symptoms, and, subsequently, improve overall outcomes. This practice is commonplace in other countries, such as the United Kingdom (Beadman & Carraretto, 2023). Understanding what training opportunities exist for psychologists in intensive care settings in the United States may help ensure the viability of these roles in the future.

To the best of our knowledge, this is the first attempt to overview psychology training opportunities in intensive care settings. Although 22 psychology postdoctoral training programs were identified, a number of challenges exist for psychology trainees seeking training in this area. First, our findings suggest that few programs offer formal training in intensive care settings. However, we recognize that our results do not offer a comprehensive list of programs, given the barriers encountered during the search process (e.g., limited databases, inconsistencies, and limitations in program descriptions). Previous work suggests the majority of psychologists practicing in critical care identify as neuropsychologists (Stucky et al., 2016). However, of the identified training programs, the majority had a recognized specialty in Clinical Health Psychology. This discrepancy may result from the relatively small sample from the previous study and relatively few training sites identified in this article, limiting both representativeness and generalization. Currently, it is likely most accurate to say the health-service psychologists from a variety of specialty backgrounds are involved in intensive care settings. Moreover, only seven programs offered training with adult critical care populations. In addition to the dearth of available opportunities, this reflects the challenges related to the search process. Notably, two affiliated institutions of the authors of this article provide postdoctoral training opportunities in adult intensive care settings, but neither program was returned in the predetermined search process, despite these training programs being listed in the UPPD.

Second, the standard search process that most psychology trainees utilize to identify training programs was limited in identifying specialty setting opportunities. Notably, the APPIC Directory produced unusable results when searching for critical care experiences in predoctoral internship programs, though it is clear opportunities exist. Subsequently, we chose to utilize the more comprehensive features of the UPPD. However, depending on the directory and search strategy, results varied greatly. Although we acknowledge that specialty training generally occurs at the postdoctoral level, we know that training opportunities exist at various levels, especially at those institutions that might offer both predoctoral and postdoctoral training programs. Unfortunately, due to this limitation, we are only able to include postdoctoral training opportunities in intensive care settings. Subsequently, we acknowledge that there are predoctoral training opportunities, but the APPIC search method precludes the ability to find them.

Third, of the programs included in our review, the specific training opportunities within intensive care settings remain equivocal. Little information is provided on either the UPPD program description or within program-specific training brochures. Few program descriptions provided details about the intensive care setting (e.g., surgical, medical, trauma, cardiac, and neuroscience) or what percentage of training time would take place in intensive care versus other settings.

In summary, this report highlights two notable barriers to obtaining psychology training in intensive care settings. First, few training opportunities exist in this rehabilitation psychology-relevant setting. Second, finding psychology training opportunities that do exist in intensive care settings is challenging. Our findings urge the importance of program descriptions that accurately and comprehensively reflect training opportunities, particularly relating to the training of psychologists to practice in intensive care settings. Limited access to psychology training in critical care reduces the feasibility and sustainability of advanced psychology practice in these settings in the future. Future efforts to establish a comprehensive list of training programs, at both the pre- and postdoctoral level, is warranted. More research establishing effective rehabilitation psychology assessment and intervention would lay a foundation for hospital administrators and policymakers to include and advocate for psychologist roles in these settings. Finally, consensus guidelines about standards of practice in ICU settings and core competencies would help inform training programs and prepare psychologists to fill an important need in health care.

Impact and Implications.

This report adds to the existing literature in rehabilitation psychology education and training as well as critical care psychology, an emerging subspecialty of rehabilitation psychology, by identifying challenges and emphasizing the need for improved directory search features for specialty training; and highlighting the gap between a current clinical need and limited psychology workforce development opportunities.