key: cord-0949657-grm7ke0e authors: Cole, Sheela Pai; Siddiqui, Shahla title: Well-being in the intensive care unit: Looking Beyond COVID-19 date: 2022-01-31 journal: Anesthesiol Clin DOI: 10.1016/j.anclin.2022.01.010 sha: f9bfa744fe07bec80031d012e068638b71c1f2fa doc_id: 949657 cord_uid: grm7ke0e Burnout among critical care personnel has increased due to the additional psychological and physical demands of caring for critically ill patients with limited resources. Factors that increase the risk of burnout include compassion fatigue, lack of control over the work environment, difficult interpersonal relationships, and constant exposure to end-of-life issues. Organizational commitment to physician wellbeing depends on improving workplace efficiency, recognizing stressors at in the critical care environment and providing resources to help manage staffing shortages. Community building, training in communication, and team-building strategies are important steps in building collaboration and camaraderie in the workplace. Critical care medicine is a subspecialty characterized by intense clinical situations balanced by immense reward in the care of critically ill patients in the intensive care unit (ICU). 1, 2 Intensivists often work in multidisciplinary paradigms, frequently engaging with other physicians, advanced practice providers, nurses, and ancillary staff. 3, 4 The critical care team works in tandem to manage complicated, life-threatening illnesses, initiate end-of-life conversations, collaborate with consultants, among many other high-acuity tasks. 4 These cumulative demands may, over time, contribute to an intensivist's perceived lack of autonomy and poor work-life balance. 5, 6 Coupled with frequent sleep deprivation, this may result in an increased incidence of depression, anxiety, and burnout syndrome (BOS) in ICU physicians compared with other physicians. 7 Burnout is more common among physicians compared to the general population. Global literature has shown a high rate of burnout within all specialties of J o u r n a l P r e -p r o o f medicine. 2 The 2020 National Physician Burnout and Suicide Report showed a 44% rate of burnout amongst ICU physicians compared to 41% of general anesthesiologists. 8, 9 The above description has been amplified by the ongoing COVID-19 pandemic not only due to dying patients, but also personal factors such as changes in workload and wages coupled with job insecurity. 10, 11 There have been a multitude of metaphorical images depicting the 'physician as hero' role, such as the submerged physician holding a patient bed afloat-in other words, saving the patient at the cost of drowning themselves. Medicine (SCCM) in their corresponding professional journals . 12 Although the statement predates the pandemic, many of the factors predisposing to BOS highlighted in the report are relevant and magnified in the current moment, such as at-risk personal characteristics, work-life balance, and organizational pressures. These factors may cumulatively lead to a high rate of turn over, poor quality of patient care and reduced patient satisfaction. Another initiative in 2020 was the Critical Care Societies' collaborative National Summit and Survey on Prevention and Management of Burnout in the ICU. The summit identified that society is at risk of losing this essential workforce and it is imperative to investigate the root causes of ICU clinician BOS. Addressing physician and caregiver well-being are important for staff retention and associated J o u r n a l P r e -p r o o f with improved patient outcomes, increased patient satisfaction, lower infection rates, and lower medication errors 13 . Well-being in the workplace is defined as "the presence of professional fulfillment and the absence of burnout" 14 Instruments for data collection such as Professional Quality of Life (ProQOL) have been used in various healthcare communities to demonstrate a direct association between the presence of compassion fatigue (i.e., the negative feeling associated with constant self-giving leading to discomfort) and an increased incidence of burnout syndrome as well as an inverse relationship between compassion satisfaction (i.e., the positive feeling associated with helping others and often the premise that leads healthcare workers to their careers) and BOS. 18 A diagnosis of BOS requires all three components, as described by Christina Maslach: high depersonalization, high emotional exhaustion, and low personal fulfillment. Finally, secondary traumatic stress is the stress experienced by witnesses to trauma, usually as a "bystander". 21, 22 This is especially true amongst ICU nurses who are frequently not decision makers but partake in the day-to day care of the ailing patient. The COVID-19 pandemic has exacted enormous healthcare, economic, and psychological burdens globally. 23 Devastating effects of the pandemic include: high rates of infection and death, financial hardships faced by society and individuals, anxiety due to J o u r n a l P r e -p r o o f uncertainty of the future, personal health-related outcomes, and stress of childcare, to name a few. 24 Healthcare workers (HCWs) are at the frontlines of the pandemic and face ongoing unprecedented challenges in treating unmanageable surges of COVID-19 patients, in working with public health officials to decrease the spread of infection, developing suitable short-term strategies, and formulating long-term plans. 25 The World Health Organization (WHO) estimates approximately 179,500 healthcare workers have died due to the COVID-19 pandemic worldwide. 26 The psychological burden and overall wellness of HCWs, and intensivists in particular, has received increased awareness, as the lay press and medical literature continue to report high rates of burnout, psychological stress, and suicide among clinicians including ICU providers. 27, 28 Reports of increased COVID-19 related stress, anxiety, depression, burnout, suicide, and PTSD among frontline ICU staff including physicians are increasing. 28 The high rate of COVID-19 mortality compounded by ongoing surges due to inconsistent vaccination in the U.S. and globally and the politicization of COVID-19 therapies and inoculation has contributed to alarming rates of emotional exhaustion and burnout among HCWs, many of whom are now leaving the profession. 20 Additional challenges faced by intensivists include: fear of infecting family and loved ones, job insecurity due to potentially protracted personal illness, anxiety regarding the supply and quality of personal protective equipment (PPE), adapting to ever-changing hospital guidelines and operating procedures and policies, sustaining physically demanding and long work hours particularly when faced with staffing shortages, and reconciling a professional commitment to helping others with the need to protect one's self. 18 Risk factors for burnout among ICU personnel J o u r n a l P r e -p r o o f BOS risk factors can be grouped into four main categories. 12 Moral injury occurs when an act is perpetrated, one bears witness to, or fails to prevent an act that is against deeply held moral beliefs. 30 The term was first used in healthcare to describe the emotional turmoil suffered by nursing personnel after long hours of patient care that ultimately resulted in an unavoidable fatal outcome. 22 Amongst healthcare providers, any act that is in contradiction to the Hippocratic oath or serves as an impediment to deliver safe care to patients may be a source of moral injury. Intensivists may face several triggers for moral injury, such as observing undue patient suffering from delays in end-of-life discussions or poor clinical decision-making, communication challenges in brain death notifications, misunderstandings regarding do not resuscitate status, inappropriate or inaccessible care delivery, poor outcomes due to health delivery disparities, psychiatric issues and addiction leading to suboptimal outcomes, and engaging with grieving families. 31 Critical care physicians are often drawn to the field to care for the seriously ill, however, complex regulatory, insurance, and quality reporting requirements have led to increased documentation and other administrative activities, drawing away from time spent that would otherwise be spent at the bedside. This incongruence between J o u r n a l P r e -p r o o f clinician ideals and the reality of clinical medicine may further contribute to feelings of dissatisfaction. 31 31 The COVID-19 pandemic has wrought additional moral injury, as intensivists continue to manage unprecedented volumes of high acuity patients and navigate unknown and often futile treatment options. 28 The moral, psychological, and physical exhaustion and injury adds to compassion fatigue, medical errors, a lack of empathy in treating patients and caring for families, lower productivity, and higher staff turnover rates. The ability of HCWs to adequately cope with these stressors is important for their patients, their families, and for themselves. Left unchecked, long term, severe stressors can contribute to significant physical and mental health problems and low 'psychological resilience' (the ability to positively adapt to adversity to protect themselves from stress). Another pandemic-induced burden to critical care personnel is the ethical constraints of shortages of ICU beds, ventilators, essential medicines, PPE, and staffing. Critical care personnel are tasked with enormously distressing difficult decisions around resource allocation, triaging patients, and assigning extremely limited resources that are essential to save a patient's life. 32 This further compounds moral burden and distress. 19 Second victim syndrome Second victim syndrome is defined as the guilt and psychological onslaught faced by healthcare providers who feel responsible following an unexpected patient morbidity or mortality event. 33 It may also refer to the struggle faced by HCWs from medical errors, unmanageably long working hours, under-supported medical practices, and lack of psychological support after a patient fatality or major adverse event. 34, 35 In addition to the primary caregiver, second victims may include colleagues called in to help during an acute event, support personnel, students, and others who may have been involved in the event or the immediate aftermath. 36 Second victims often experience fear, guilt, self-doubt, shame, anger, reliving of the event, sleep disturbance, and anxiety. 37, 38 These emotions mirror symptoms of acute stress disorder and post-traumatic stress disorder and may affect HCWs both at work and at home. Such emotions may persist for weeks to years and lead to burnout, substance abuse, and even suicide. In a 2012 national survey of the impact of perioperative catastrophes on anesthesiologists, over 60% of respondents experienced depression and 19% indicated that they never fully recovered from the experience and felt that their ability to provide care for the first four hours after an adverse event was impaired. 38 Although there is a dearth of literature among ICU physicians, the rate of second victim syndrome has been shown to be anywhere from 10-40% in this group. 35 Solutions to mitigate burnout and improve intensivist fulfillment Below, we describe pandemic-specific measures to address well-being and discuss longterm solutions to mitigate BOS and improve overall well-being in the critical care community. The pandemic reified the importance of workplace community in mitigating burnout and promoting well-being. Clinical leaders can build and reinforce resilience in their teams by displaying compassion. In the authors' collective experience, we have witnessed thoughtful leaders checking in frequently, listening to feedback, providing wellness resources and support, and demonstrating compassion to their team. 41 identifies opportunities for future growth and create collaborative scenarios between teams. 48, 49 In a single center post code debriefing survey, code response satisfaction improved 50 attendings shared most of the day and nighttime service for two teams over a two-week period with creative assignments to avoid thirty plus hour shifts. 54 This simulation study found more continuity of care and less handoffs, making it safer for patients while facilitating improved intensivist work-life balance with more weekends off throughout the year. Further implementation data on this simulation paradigm is awaited. Advocating for personal well-being strategies such as self-care, self -forgiveness, and mindfulness may anecdotally help with reducing burnout and increasing professional well-being. However, institutional support in incorporating efficient practices and building a culture of J o u r n a l P r e -p r o o f wellness through systems-based changes may be more effective in recruiting and retaining a well workforce. 3, 39, 40 Appointing institutional or departmental well-being officers who are well versed in clinical workflow inefficiencies and have the skillset to advocate for their peers and colleagues are essential in supporting an institutional commitment to clinician well-being. 11 Finally, the COVID-19 pandemic has created a unique psychological quagmire amongst critical care professionals. 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