If you say Hello, can I say goodbye? A critical reflection on the limits of positive-communication interventions in ICU teams

The Hello study [1,2] reports a statistically significant reduction in burnout following a four-week intervention promoting positive communication. This is an encouraging result in an international institutional context where many clinicians report increasing difficulty experiencing themselves as caregivers. Yet behind the success of a playful and unifying initiative that engaged ICU teams on a large scale lie several important psychological concerns.

The Hello intervention relies on a form of “positive psychology” criticized for promoting individual behavioral prescriptions while leaving organizational determinants unaddressed [3]. In practice, the intervention establishes an emotional norm in which being positive - greeting, thanking, or complimenting others - becomes a moral expectation. But do these gestures truly reflect authentic positive relationships? Elevating such an approach to a model risks creating a form of emotional policing, in which expressing frustration, fear, or disagreement becomes less legitimate because only positively coded signals are recognized as valid expressions of working together – a phenomenon which mostly affect women’s voices [4], who constitute the majority of healthcare workforce. Such emotional norms also overlook cultural differences in how healthcare professionals express respect, care, or affiliation.

Avoiding conflict - an inevitable feature of any human collective - also leaves a central issue unresolved: what becomes of experiences that cannot be expressed positively, particularly in ICU settings where much of the distress arises from ethical tensions? By prescribing positivity as a norm, the intervention may inadvertently render distress invisible, silencing complaint and moral discomfort, precisely the material required for meaningful preventive action.

Our intention is not to dismiss interventions grounded in positive communication; several studies suggest, such as the Hello study, that they may support relational dynamics and contribute to a more supportive work climate [5]. However, as emphasized in a recent editorial in Intensive Care Medicine, such improvements coexist with persistently high levels of burnout, highlighting the limits of interventions that do not address underlying organizational and structural factors [6]. When intrinsically individualizing tools are presented as major solutions to burnout, they risk functioning as a screen that protects institutions from questioning their own responsibilities [7]. These concerns are consistent with ICU research: recent meta-analyses show that burnout among ICU nurses and physicians is largely driven by organizational determinants including workload, work environment, limited time for adequate care and interprofessional coordination [8].

Multiplying behavioral prescriptions cannot replace the opportunity for teams to collectively develop their own norms of functioning [7]. ICUs are, in this sense, small “cities”: dense communities of practice shaped by ethical dilemmas, strong emotions, and daily trade-offs which require institutional discussion spaces to help to resolve ethical tensions pertaining to the conflicting ends with which healthcare institutions wrestle [9]. Sustaining a workable climate requires that clinicians be able to discuss their experiences, confront divergent viewpoints, debate what they consider good and just, and co-construct the relational norms they wish to implement in their units.

Consent for publication

Not applicable.

Ethics committee approval

Not applicable.

Funding

Not applicable.

Data availability

Not applicable.

Declaration of competing interest

None of the authors has any potential conflicts of interest to disclose.