Intensive care unit stress and burnout among health-care workers: The wake-up call is blaring!

Since late December 2019, the city of Wuhan in China has reported a novel pneumonia caused by coronavirus disease 2019 (COVID-19), which has now spread domestically and internationally.[1] The virus has been named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The COVID-19 pandemic has caused unthinkable consequences and has challenged and, in numerous cases, beaten the capacity of hospitals and intensive care units (ICUs) worldwide to handle it.[2] Apart from the obvious burden of patient care, extended work timings, and fear of personal safety, health-care workers (HCWs) also suffer from occupational stress as a result of lack of skills, organisational factors, and low social support at work, leading to distress, burnout, and psychosomatic problems. This leads to stress, direct deterioration in quality of life as well as quality of service provided.[3] In this article, the authors navigate on the root cause of stress that is peculiar to the HCWs deployed in the ICU and suggest recommendations to alleviate it. To aid in the research, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, NIOSHTIC-2, and Web of Science up to May 2021.

Stress is an integral part of every workplace. However, the ICU is a highly stressful environment, not only for patients and relatives but also the ICU staff (doctors and nurses) with a proportionately greater amount of work-related stress than most occupations.[4] The ever-increasing number of confirmed and suspected cases, overwhelming workload, depletion of personal protection equipment, widespread media coverage, lack of specific drugs, and feelings of being inadequately supported may all contribute to the mental burden of these HCWs. Under usual working conditions, severe burnout syndrome affects as many as 33% of critical care nurses and up to 45% of critical care physicians.[5] Following the outbreak of SARS in 2003, HCWs reported chronic stress effects for months to years. During the acute phase of the SARS outbreak, 89% of HCWs who were in high-risk situations reported psychological symptoms.[6] Among HCWs treating patients with COVID-19, a Chinese study reported high rates of depression (50%), anxiety (45%), insomnia (34%), and distress (72%).[6,7]

Burnout on the other hand is a pathological syndrome, first described in relation to warfare, in which prolonged occupational stress causes emotional depletion and detachment.[8,9] It has been defined in terms of emotional exhaustion, depersonalization, and a sense of reduced personal achievement.[10,11] It may also present as depression, high absenteeism and sickness rates, drug and alcohol dependence, or chronic physical complaints.[12] Occupational stress and burnout are therefore important for the individual and for work productivity and efficacy.

Beyond burnout, 39% of physicians report depression and about 400 physicians die by suicide each year, which is twice the rate of the general population. The suicide rate among women doctors is about 130% higher than the general population, while male doctors experience a 40% higher rate. ICU nurses also report high rates of burnout and depression, as well as high rates of posttraumatic stress disorder symptoms.[7]

Stress arises when an individual feels obliged to respond to a situation but is unable to cope with the situation's demands.[8] Stress is subjective, and the susceptibility to various stressors varies from person to person. Among the factors that influence the susceptibility to stress are genetic vulnerability, coping style, type of personality, and social support.[9] The impact stress has on an individual therefore depends not only on the nature and severity of the stress but also on the psychological makeup of the individual. Researchers have long suspected that the stressed-out personalities have a higher risk of high blood pressure and heart problems, asthma, obesity, diabetes, headaches, depression and anxiety, gastrointestinal problems, and Alzheimer's disease.[9] Because stress is essentially subjective, it is logical that coping with stress should also fundamentally be a subjective process. Coping with stress means solving problems that can be solved and converting those that cannot be solved into positive challenges. Learning to cope with stress involves learning techniques that bolster our resistance to stress.[8]

UNIQUE CHALLENGES FACED BY HEALTH CARE PERSONNEL

So what makes HCWs in the ICU most prone to stress and burnout? Many factors have contributed to the present state of stress among HCWs. A few of them are:

1. Increased patient care demands: Many more patients present for care, most of them being severely or critically ill posing an increased demand on a health-care system with limited workforce resources. This often poses increased work demands with longer shifts or no breaks, often working under stressful conditions

2. Workload: Workload is not only a matter of long hours, but a combination of the demands of the task, and efforts that need to be made to deliver these tasks. Increased hours of clinical responsibility are related to greater fatigue, which in turn aggravates the effects of other stressors more severely

3. Equipment related challenges: The deficiency of essential life-saving equipment (Ventilators, oxygen supply, etc.) can stall optimal patient care, despite own professional expertise. The protective equipment can be uncomfortable to wear over extended hours, with limited mobility and scope for communication. Occasionally, shortages may occur for one or other protective equipment/s leading to anxieties related to exposure

4. Emotionally challenging experiences: Patient distress related to their condition can be increasingly difficult to manage for health-care personnel and can take a toll. The infection can lead to mortality in spite of best of efforts put in by health-care personnel. Such experiences may be emotionally draining for the HCW

5. Not trained to tackle stress: Medical students, residents, and staff training to work in the ICU are not optimally trained to handle stress. Since the education framework only focusses on management of the illness, handling the added burden of stress that comes with the management becomes overwhelming. While it is important to educate doctors and nurses regarding stress management, it is just as important to have tangible change within the hospital environment too to address the same

6. Surge of other diseases: Since the world focused all its attention and resources to the research and treatment of the pandemic, there has been an increase in non-COVID-related health problems and deaths (e.g., those caused by disruptions to routine out-patient services or screening programs for other infectious diseases, further increased work load in the ICUs[2]

7. Biorhythm disturbances: Sleep repairs the physical body to improve and maintain general health, consolidate learning and memory, and recharge the psychological batteries to maintain emotional balance and well-being. Sleep disturbances lead to various mental and physical illnesses including an increased risk of hypertension, diabetes, obesity, heart attack, stroke, and depression. The problem of sleep comes with shift work, typically associated with the work schedules in ICUs.

8. Fragmentation of available social support: The fear of transmitting COVID-19 led many health professionals to isolate from their families for months due to the increased risk of contracting the infection during patient contact and passing it along to one's family members or relatives. This has caused HCWs to feel lonely and vulnerable

9. Shunned by society: HCWs have been subjected to denigration from various sources during the pandemic including domestic help and community support. Working remotely and being shunned by help providers only added onto the agony

10. Gender inequality: COVID-19 has had a disproportionate effect on women HCWs. Women comprise 70% of the global health and social care workforce, putting them at risk of infection and the range of physical and mental health problems associated with their role as health professionals and carers in the context of a pandemic. The pandemic exacerbated gender inequities in formal and informal work, and in the distribution of home responsibilities, and increased the risk of unemployment and domestic violence. While trying to fulfil their professional responsibilities, women had to meet their families’ needs including childcare, home schooling, care for older people, and home care.[2] After controlling for confounders, being a woman and having an intermediate professional title were associated with severe symptoms of depression, anxiety, and distress[6]

11. Lack of integrated mental health resources: Psychological assistance services, including telephone-, internet-, and application-based counseling or intervention, have been widely deployed by local and national mental health institutions in response to the COVID-19 outbreak throughout the world. The Internet is replete with information and more misinformation,[10] however, evidence-based evaluations and mental health interventions targeting front-line HCWs are relatively scarce.[6]

WHAT ARE THE RED-FLAG SIGNS OF STRESS AMONG HEALTHCARE WORKERS?

There are some signs that may raise concerns that a doctor is getting into difficulty. The signs would suggest the need for an approach to the trainee by a skilled senior doctor or their training supervisor, to identify any underlying factors, and to set clear goals for improvement.[11]

1. The disappearing act – not answering bleeps; disappearing between clinic and ward; lateness; and frequent sick leave

2. Low work rate – slowness in doing procedures, clerking patients, dictating letters, making decisions; arriving early; and leaving late and unable to finish all the tasks

3. Ward rage – burst of temper, shouting matches with other members of team (nurses, midwives, secretaries, etc.)

4. Rigidity – poor tolerance to healthy criticism, inability to compromise, difficulty prioritising, and inappropriate whistle blowing

5. Bypass syndrome – junior colleagues and nurses find ways to avoid seeking the doctor's opinion or help

6. Career problems – difficulty with exams, uncertainty about career choice, and disillusionment with medicine.

7. Insight failure – rejection of constructive criticism, defensiveness, and counter challenge.[12]

RECOMMENDATIONS

Working in the front line has been an independent risk factor for poor mental health outcomes in all dimensions of interest. It is important that to device strategies for ensuring self-care and well-being of front-line HCWs involved in the pandemic. A few tips to ensure that mental health is nurtured are enumerated below:

Recommendations for health care worker

1. Meet your basic needs on regular basis. Maintain a regular eating, drinking, and sleep schedule, adjusted to your duty shifts. Neglecting the basic needs puts you at higher risk and may affect your ability to care for patients.[13] Make sure that your nutrition is not compromised and that you are well rested

2. Take designated breaks. Give yourself a rest from patient care. If possible, do something unrelated to medical care such as listening to a song or talking to a friend or simply doing deep breathing exercises. Music, for instance, a known tool for relaxation, of different styles may help you to relax at different times and in different ways. A warm, candle-lit bath whilst listening to soft classical music may work sometimes, whereas loud rock music may help you to release pent up tensions through dancing and/or singing along. Remember that appropriate rest or relaxation leads to proper care of patients after your break is over

3. ”Problem-Focused” coping style. Problem-focused coping is made up of two strands: “Problem-Solving” and “Stress Reducing Appraisal.” The former uses deliberate policies of simplification (start with the most obvious steps when faced with a problem), prioritisation (deal with the most important things first), and delegation (delegate when possible) to reduce the number of stressful events the individual is exposed to. The latter aims to reduce the emotional load of the stresses that remain – in this case by: (i) accepting that difficulties are an inherent part of the working environment, (ii) accepting that there are physiological and psychological limits to what can be done – and that these limits do not necessarily imply failure, (iii) accepting that periods of high demand are an inevitable component of our career and finally, and (iv) Retaining the right to say “No.” These simple steps help the stressed individual to accept the stress they are exposed to, divorce them from a sense of failure, and encourage a more constructive coping response[14]

4. Remain connected with family and friends. Studies have shown that ICU staff who were not spending time with family and or friends were more likely to be in stress than ICU staff who were spending more time to the family and friends.[4] Keep in touch with your family and close friends who form your support network outside the health-care system. Sharing your feelings and staying connected with them may help in de-stressing you

5. Communication with your colleagues. Talk to your colleagues and extend as well as receive support from each another. Identify the problems or challenges being faced in delivery of health care, work on effective solutions to ease the burden of care, and exchange constructive ideas

6. Stay updated on latest scientific information. Gather information from credible sources of information and keep yourself updated on daily basis. Participate in workplace discussions to stay informed of the latest status and guidelines. Use tele-conferencing to connect, communicate, and learn

7. Limit media exposure. A continuous stream of news and updates on social media platforms and variety of news outlets can eat into your time, increase your stress, and may reduce your effectiveness. Try to monitor the unnecessary exposure to media, setting a strict time limit[10]

8. Appreciate the “superman” status of your profession. There may be times when it seems challenging to provide constant care for those in need. However, it may help to remember the noble calling of medical profession – taking care of those most in need, which might be reassuring and fulfilling. Give due honor to yourself and your colleagues’ services toward those in need. It is an opportunity to service only a privileged few get to deliver

9. Gauge your mental or emotional health. Monitor yourself over time for any symptoms of excessive anxiety or depression or prolonged stress such as changes in mood, insomnia, intrusive memories, hopelessness etc. Talk to a friend, trusted colleague, or seek professional help if needed

10. Take professional help. Once burnout has set in, and the red-flag signs as mentioned above are visible, there is limited evidence to support the usefulness of modalities such as cognitive behavioral therapy, relaxation, music, or creating a positive work environment. Treatment then involves medical intervention. Prevention appears to be, once again, far more beneficial than treatment when it comes to burnout. However, if faced with stress or burnout, do not hesitate to seek professional help.

Recommendations for management/government

1. Train health-care professionals to combat stress. Stress management lessons should be part of the curriculum of HCWs, especially for those who are trained to work in the Emergency Room (ER) or ICUs

2. Organisational interventions such as change in working conditions, organising support, increasing communication skills, and changing work schedules. Changing work schedules (from continuous to having weekend breaks and from a 4-week to a 2-week schedule) reduced stress[3]

3. Online tele-mental health including Internet-based counselling/intervention should be provided by the administrative authorities in various health-care institutions.

CONCLUSION

Stress is an inescapable reality for HCWs in the ICU settings. It is incumbent for HCWs to acknowledge, monitor, and take active steps for self-preservation. By recognizing the cohesion of psychological distress among HCWs during COVID-19, we can destigmatise work-related mental health issues. Finally, we can only hope that the COVID-19 pandemic will recognize the contribution of all the HCWs and prompt a redefinition of essential support workers with appropriate education, protection, and compensation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.