Resilience and Stress Are Heterogenic Too: We Should Act Accordingly

To the Editor:

The recent article by Azoulay and coworkers highlights a very important issue, the mental health of the people providing critical care and how resilient they are to the high stress levels of pandemic circumstances (1). However, I do have some concerns with the analysis.

First, the analysis seems to aggregate the results in doctors and nursing staff members. Both are equally important, but the patterns of occurrence of stressors can be very different in these groups. Also, some of the tested variables are very different for doctors and nursing staff members. For example, it is far easier for doctors to care for more than 50 patients in a wave than it is for nurses, as the number of patients cared for in a single shift is usually quite different between a single doctor and a single nurse. Nurses have a tighter bond with their patient because they care for this patient continuously at the bedside, whereas most doctors have to divide their attention among far more patients. Because of this tighter bond, the death of a single patient is more likely to have an impact on the nurse than on the doctor.

Furthermore, in my experience, doctors have fewer problems with their span of control being stretched by the necessity of caring for more patients because doctors are already trained to care for larger numbers of patients than nurses. In most Dutch ICUs, nurses are trained to be “control freaks,” to control every detail of their patient. Caring for more patients at the same time and delegating some of these details to less trained staff members sometimes induces moral stress.

Second, resilience and susceptibility to stress are factors that show high degrees of heterogeneity, likely with high inter- and intrapersonal variability in threshold levels and responses to certain stressors at certain times. The success of interventions to increase a person’s resilience to stress are probably highly dependent on whether the intervention fits the person. Therefore, I would not recommend they be studied with randomized controlled trials because this is likely to go the same way of most intensive care trials in populations with a high degree of heterogeneity.

The perceived low support by institutions is indicative of a major lapse in policy and is, in all likelihood, not isolated to France. Institutions must act to detect mental health issues and their predisposing factors in their personnel. They must also offer interventions to counteract these predisposing factors, such as increasing resilience. However, it should not be a one-size-fits-all approach; different people require different interventions.