Dear Editor,
Healthcare personnel who work for prolonged periods in highly stressful environments are susceptible to the effects of these stressors and the cumulative nature of their exposure. The term ‘burnout’ has been coined to describe a constellation of symptoms related to work, organisational and personal issues occurring in individuals with no prior history [1]. Burnout has been described as particularly prevalent in the critical care setting [2–4]; it affects not only the health and wellbeing of those individuals experiencing the deleterious consequences, but also the quality of the care they provide [1]. There is significant literature that supports the worthiness of mentorship [5–7] throughout medical training. Following on from our paper exploring the behavioural responses of intensivists to stressors encountered working in the intensive care environment [8], the aim of this study was to elicit the advice senior intensivists might offer others on dealing with the stresses of a career in intensive care.
This study was conducted at three sites, in two countries between September and October 2018. Participants were intensivists who had more than four years of experience working in the intensive care unit (ICU) setting. The trial was registered in the Australia New Zealand Clinical Trials Registry ACTRN 12619001314112. Ethical approval was granted by Sir Charles Gairdner Hospital HREC (Lead site: RGS0794); the Austin Hospital (HREC/18/OTHER/14); and Hadassah University Hospital (0313-18HMO). An example of a question pertaining to data reported was: “If you could travel back in time and talk to a younger version of yourself, what sort of advice would you give yourself about the stressors of working in intensive care and the manner in which you might prepare for and manage them, in order to maintain a positive state of mental wellbeing?”
The responses were audio-record-ed and transcribed. A codebook was developed and agreed upon by two investigators (DD and RK) across a sample of the transcripts using NVivo software (Version 12, 2018 software; QRS Pty Ltd., Victoria, Australia). All transcripts were then independently coded by two investigators (DD, RK, CK or PVvH) using a framework analysis methodo-logy [9] with any newly identified codes subsequently explored in all transcripts retrospectively by one investigator (DD). Common themes were then recognised, discussed and agreed upon by all investigators, and verbatim quotations were selected to support thematic choices.
Nineteen participants (Australian, n = 13; Israeli, n = 6) contributed to the dataset and five themes of advice emerged from data analysis (see Tables 1–5). These concerned prevention of error; preparation of self; the nature of the workplace; responses to emergency situations; and management of emotional responses. Uncaptured in the objective results outlined was the tone and manner with which the intensivists engaged in the interview process. The advice provided by the senior intensivists was, in the opinion of the interviewers, given in a wistful and pragmatic manner. There seemed to be a genuine effort to help guide and help junior colleagues in their careers by imparting useful information.
TABLE 1
Theme 1: Prevention better than cure
TABLE 2
Theme 2: Preparation of self
TABLE 3
Theme 3: Acknowledging the nature of the workplace
TABLE 4
Theme 4: Strategies to respond to real-time emergent situations within the workplace
TABLE 5
Theme 5: Managing the emotional responses in the aftermath of adverse events, mistakes and deaths
The senior intensivists advised that “prevention is better than cure” and one way to achieve this was “to know your subject and your job well”, so mistakes are not made from ignorance about circumstance or lack of clinical knowledge. Attention to detail and being prescriptive and vigilant in communicating were seen to be important in a workplace where teamwork was viewed as essential. There was no room for the assumption that everyone knows what the team-leader wants or means, and establishing routines for everyday work practices, with explicit expectations for each team member, was important. Having “healthy scepticism”, with advice to check and verify everything rather than rely on the opinion or word of others was imperative. This gathering of facts, although burdensome, offered comfort and reassurance that details pertaining to the patients were correct.
Self-belief and belief in the ICU team’s collective capabilities were important. Acknowledging individual fallibility and the inevitability that, despite best efforts, there will be errors and adverse events was also vital, along with an awareness of the emotional impact of the work. Choosing a well-suited mentor and role model may provide a valuable example of how to behave and cope. Coping strategies included such things as recognition of fatigue; not making rash decisions while fatigued; separating work and private life; not carrying over problems from one domain to the other; and finding coping strategies, such as physical activity and mental strategies. Some emotional coping skills were also recognized as being very important, such as forgiveness (both of oneself and others), in order to release ourselves from the burden of conflict or the consequences of an adverse event. Bringing kindness into the work environment, towards ourselves, colleagues and patients, can go a long way to reducing tension in a stressful workplace.
The nature of the workplace needs acknowledgement and perspective was important. Sometimes bad things happen because of systemic problems in the institution [10]. The intensivist- in-training should guard against apportioning blame and passing judgement too quickly and/or too harshly – either on themselves or their colleagues – as this is not conducive to the investigation, clarification and learning that can come from an incident. Taking overall responsibility and shared ownership for the quality of care and patient welfare provided was seen as an essential skill. The verbatim quotes listed in the Tables 1–5 provide excellent examples and illustrations of this above distilled advice.
Although investigators agreed that data saturation was met within the sample, the main limitation of this study was that it provides a snapshot of the opinions of only a small group of intensive care doctors, and only those working in two countries. It follows that other themes of advice may have emerged from a wider intensivist sample. A career in intensive care is not an easy one. Intensivists need to learn how to manage and prevent errors, stressful work environments and the sequelae of physical and mental exhaustion without burnout. It behoves up-and-coming intensivists to learn from the advice afforded by senior colleagues who have successfully navigated a career in the specialty. Their advice is eloquently illustrated in the tables attached to this paper.
