Behind the Mask of ICU Healthcare Workers

ICU healthcare workers (HCWs) are consistently exposed to challenging situations: high patient complexity and acuity, bearing witness to cardiopulmonary resuscitation, patient suffering and death, and engaging in care perceived as futile (1, 2). Ongoing exposure to these emotionally charged experiences may increase the risk of passive trauma, also known as vicarious trauma (1, 2). Failure to recognize and address the often silent and insidious development of passive trauma may propagate a vicious cycle of HCWs’ moral distress and attrition (3), leaving those remaining with mounting workload and distress.

The American Psychiatric Association first incorporated post-traumatic stress disorder into the Diagnostic and Statistical Manual of Mental Disorders in 1980 (4). The definition of post-traumatic stress disorder was expanded in 1994 to include both direct and indirect traumatic events, acknowledging that individuals, including HCWs, can experience trauma from witnessing it (5). This has been followed by a growing awareness of the mental health implications for HCWs, particularly in a high-stress workplace such as the ICU. Evidence around passive trauma resides mostly in the nursing literature, with limited information on physicians. A survey of physicians from various specialties highlighted that 79% had experienced at least one traumatic event in the past year (6). However, very few reach out for help, fearing judgment and negative consequences for their careers (7).

For ICU physicians, one of the initial encounters with passive trauma occurs during training, a time when learners develop their professional skills and shape their professional identities. Training exposes them to a variety of patient experiences, from the hopeful discharge of a patient from the ICU to the difficult reality of those who will never recover and will die. Trainees regularly confront the stark reality of patient death and their role in consoling grieving families. Concurrent with this, they simultaneously navigate the administrative and paperwork aspects of death, while dealing with the cognitive load of a pager that never stops ringing and an endless list of tasks. Nurses engage in the tough emotional act of cleaning the patient’s body and minimizing the physical stigmata of invasive supports, such as endotracheal tubes and invasive lines, which can leave lasting scars on both patients and HCWs. Every member of the interprofessional and multidisciplinary team is affected, including housekeeping staff members, sometimes forgotten, who witness the evolution of a patient’s illness, the outcome, the impact on family, and the final act of zipping shut the bag of a deceased patient. There may be no time for reflection, as this is frequently followed by an urgency to clean the room for the next admission. Although perceived as the “usual” for ICU HCWs, this dynamic should not be normalized, and the emotional toll of these events on the team warrants acknowledgment and intervention.

In the wake of these intense experiences, a sense of guilt or regret may arise: Did I miss anything of clinical consequence? Should I have initiated a treatment sooner? Is this what the patient wanted? ICU physicians make decisions that significantly affect patients’ trajectories, ranging from starting fluids and antibiotics to implementing extracorporeal life support. Rooted in the delicate balance of beneficence, nonmaleficence, respect for patient autonomy, and distributive justice, these decisions accompany us, challenging the boundary between professional duty and personal well-being.

Perceived futility, a recurring theme in the ICU, adds another layer of complexity to the passive trauma experienced by physicians. A study revealed that HCWs perceived 1 in 10 patients to receive futile treatment and noted that 85% of these patients died within six months (8). The cost of futility of care for patients and for the healthcare system are frequently highlighted, but the consequences for HCWs are often ignored (9). Continuing to engage in treatment perceived to be futile may cause moral distress. The repetition of these events, in an environment that does not validate its emotional impact, fosters a culture in which physicians conceal their distress behind a mask of normalcy and their voiced assurance that they are “fine.” In response to this, physicians may adopt maladaptive coping strategies, including refraining from any patient contact or careful clinical examination, overlooking severe muscle weakness, scars, or pressure injuries from prolonged bed rest. Others may engage in superficial, accelerated medical rounds to minimize time at the bedside to escape an uncomfortable reality, and some may avoid challenging goals of care conversations with patients and their loved ones. The cumulative effect of this maladaptive culture is to promote moral distress, passive trauma, and intention to leave the healthcare profession, leaving individuals and the healthcare system in crisis (10, 11).

In addressing passive trauma within ICUs, the following strategies may be considered. First, normalize discussions about passive trauma to create an environment in which such conversations are routine and promote a culture of support between HCWs (12). Second, invest in training designated peer supporters—as site leads, managers or a dedicated team—to recognize signs of distress and provide support and redirection if needed. This has been suggested by the ForYou (12) and Resilience in Stressful Events programs (13), developed to assist HCWs traumatized by witnessing adverse events. Last, establish a clear escalation system that includes professional psychological support, ensuring that all HCWs are informed about it and able to access additional support as needed (12, 13). Despite the lack of evidence favoring specific interventions in ICUs, a peer support system (12–14) and psychological support (14, 15) have proven value among first responders and in surgical training programs. However, their integration into ICU settings remains uncommon. The evidence is overwhelming that ICU HCWs are experiencing a mental health crisis. Are we ready to take action?

There is an urgent need to break the silence, change our work culture, encourage open discussion, and implement strategies to mitigate the consequences of passive trauma. The prevailing idea that HCWs are invulnerable “heroes” needs to be dispelled. In advocating for the acknowledgment of passive trauma and for the support of HCWs, we forge the path for a healthier work environment. This will enhance the provision of comprehensive and empathetic care of critically ill patients and keep our healthcare system intact and functional.