Burnout, stress, uncertainty: Pandemic reaps widespread effects on critical care teams

Caring for the care professional is key during the COVID-19 pandemic.

A session at the Society of Critical Care Medicine Congress focused on emotional resilience during difficult scenarios, managing stress about uncertainty in debriefings and protocols, and building resilient trainees during a pandemic.

J. Christopher Farmer, MD, MCCM, who has a three-decade career in critical care medicine and today is president of the Trajectory Group, a health care-focused management consulting service, said before moving away from bedside critical care, “I didn’t fully realize — I should have but I didn’t — the impact of day-in-and-day-out in the ICU [and] the degree of compartmentalization that is required in order for us to continue to function, to hold emotions in check and to be clear-minded as we make difficult decisions every day.”

Before the COVID-19 pandemic, moral distress and burnout in critical care were already high, according to Farmer, who is also emeritus professor and chair at the Mayo Clinic in Arizona and a past president of SCCM.

“Now we come to coronavirus, and we stack all of that on top of a system that is already strained,” Farmer said. “We see this anger, frustration, guilt, powerlessness, and we have all of these things that were already going on that were made worse by the aspects of coronavirus at the bedside.”

Farmer focused on emotional resilience during difficult patient scenarios. Resilience, he said, involves love, insight and acceptance. Workload, moral distress and resource availability all have a great impact on the ability to maintain some level of acceptable resilience, as well as quality of interdisciplinary teamwork and patient safety, Farmer said.

Examples of COVID-19 and moral distress, he said, include:

• Isolation: isolation between patients and their family members not allowed in the hospital; between patients and caregivers in personal protective equipment (PPE); between caregivers and the care team; decision-making in isolation;
• Communications: changes in communication such as telemedicine and FaceTime calls with family members not allowed in the hospital; communication issues between caregivers and the care team;
• Uncertainty: uncertainty of isolation and communication on care profiles, uncertainty about the risks of disease transmission and mortality, uncertainty of clinical treatment knowledge during the pandemic, not knowing what comes next;
• Saturation: heavy workload, care quality, emotional, decision-making in isolation; and
• Death: seeing many patients die during the pandemic.

The emotional toll of resource allocation during the pandemic “is very, very high,” Farmer said, with examples over the past 2 years including a lack of hospital beds for sick patients, allocating mechanical ventilators and patient transfers without adequate resources.

There is a lot of focus on burnout among health care professionals and strategies to address the root causes of the problem, Farmer said.

“As we go forward ... maybe there is some structure that we need to put in place for ... how we better support ourselves,” Farmer said.

When it comes to building resiliency, Farmer said: “It’s OK to talk about it with others. We are a team. We do team-based problem solving. We do team-based care — not just for our patients but for each other.”

Managing stress around debriefings and protocols

It is important to manage clinician stress about uncertainty through debriefings and protocols, according to Michael G.S. Shashaty, MD, MSCE, FCCM, rapid response medical director and assistant professor of medicine at the Perelman School of Medicine at the University of Pennsylvania, said during a presentation.

“Uncertainty is everywhere in medicine, magnified by the COVID-19 experience. Debriefing and protocols go hand in hand to reduce the stress of uncertainty associated with high-stakes clinical scenarios,” Shashaty said.

Debriefing is generally defined as a post-event discussion between two or more individuals in which the aspects of performance are analyzed with the aim to improve future performance. Debriefs are held either immediately after the event or at a later time.

Some parts of debriefing can contribute to stress — for example, excessive focus on shortcomings, blaming language, failure to discuss concerns and/or opportunities and competing demands on time, Shashaty said.

Shashaty highlighted solutions that can help minimize stress surrounding debriefings, including listing the pluses, or positives, and asking about opportunities to make change; setting a positive tone; encouraging “I” statements; volunteering areas for improvement; and keeping it brief.

Using his own institution as an example, Shashaty discussed development of a “Clinical Emergencies Guide” at Hospital of the University of Pennsylvania during the initial COVID-19 surge at that hospital.

“Disseminating new clinical emergency guidelines was a major challenge. ... We used debriefs as an opportunity for education to disseminate some of these protocols. ... We tried to marry the protocols with the debriefing whenever possible,” he said, noting that reception was very strong just after an event when the clinical relevance was so evident.

Protocols can aid in decision fatigue, with several other advantages including quick adoption of new information to the bedside and streamlining care. However, protocols can also be oversimplified, can lead to loss of individualization of care and have the potential to be obsolete if not kept current, according to Shashaty.

“These tools help to unify the clinical team. Everyone experiences clinical stress; sharing experiences highlights this. Standard clinical practice connects providers,” Shashaty said.

Strategies to build ‘resilient trainees’

The COVID-19 pandemic “brought new stressors — stressors that were particularly difficult for trainees who are new to the health care environment, and particularly new to the critical care setting,” Marian E. Von-Maszewski, MD, associate professor of critical care at The University of Texas MD Anderson Cancer Center, said during a presentation.

Some of the new stressors for trainees throughout the COVID-19 pandemic included fear of the unknown; a new working environment, with continuous PPE; a need for new skills, like conducting virtual visits; newly developed staffing models; ever-changing treatment strategies, based on new knowledge of COVID-19; social isolation from colleagues, family members, friends and their own trainee groups; and increased responsibility while preparing for the next pandemic wave, Von-Maszewski said.

Many of these stressors can lead to burnout, with high levels of emotional exhaustion and depersonalization and low levels of personal effectiveness and accomplishment, Von-Maszewski said.

Strategies developed over the past 2 years have been created to help build resilient trainees, according to Von-Maszewski. Some of these strategies include:

• on-site support involving paired relationships for daily check-ins, effective debriefing sessions and encouraged use of virtual resources;
• mentor relationships with smaller mentor-to-training ratios to support more frequent in-person meetings;
• virtual resources, such as employee assistance programs, wellness resources, and medical and professional society offerings;
• maintain education, including educational activities, conferences and research along with matching responsibilities to the correct level of training a trainee may have; and
• sustainability focusing on longevity, vacations and conferences, interests, engagement, remote work and recognizing mental health needs.

Building resilient trainees “is a skill that none of us were aware we really needed 3 or 4 years ago. ... And now we understand how we can better continue to educate our trainees and keep them safe, both physically and emotionally, during a pandemic,” Von-Maszewski said.

“As critical care educators ... it’s important to not only teach the lessons I’ve discussed here, but to make sure that you’re taking care of them yourself because one of the biggest ways that our trainees learn is by watching what we do and how we respond.”