Psychology | Higher education » Promoting Psychological Wellbeing and Reducing the Risk of Burnout in Critical Care Staff

Source: http://www.doksinet Promoting Psychological Wellbeing and Reducing the Risk of Burnout in Critical Care Staff Page Introduction 1. A psychological understanding of workplace wellbeing Julie Highfield, Dorothy Wade 2. The prevalence and scope of work related psychological stress in critical care. 3. The Impact of work related stress (personal, organisational, workforce/economic) 4. Risk factors in critical care practitioners; recognition and diagnosis 5. Escalation and management strategies Gareth Cornell, Richard Innes, Laura Vincent Danny Bryden, Gareth Cornell, Jonathan Goodall L-J Mottram, Dorothy Wade 6. Best practice – examples and case studies (UK and worldwide) 7. From training to retirement: managing career phases & achieving longevity Part B: recommendations 8. Individual/peer-to-peer (resilience, prevention, recognition & actions) Julie Highfield, L-J Mottram, Peter Brindley Peter Brindley, Jamie Strachan, Segun Olusanya Danny Bryden, John Elmore,

Fiona Wallace Outline attached – Julie Highfield, Danny Bryden 9. Organisational (workforce planning, and additional support) 10. Resources & toolkits (existing/best practice, and indications for new work) 11. What don’t we know yet? Signposting for next directions 1 Source: http://www.doksinet Introduction Delivering healthcare is a major human endeavour. For example, the United Kingdom’s National Health Service (NHS) is the fifth largest employer in the world, comprising over 5% of the entire UK working population and employing twice as many people as the top 100 UK private sector employers combined1 Looking after the wellbeing of healthcare workers – and by extension all those they care for - is an issue of huge importance to society. There is evidence that UK medical2 and nursing staff 3 are experiencing high levels of work-related stress and burnout. This document focuses on the field of critical care medicine and reviews both the current data and future research

priorities. Critical care offers challenges to personal balance and wellbeing, which include, but are not limited to, concentrated prolonged engagement with patients and families, potential for poor outcomes, the need for complex decision-making, a 24/7 workload, and the ubiquity of moral distress. On the other hand, there can be substantial rewards and protections. These include teamwork and peer support, predictable duties, a defined area of work, the privilege and challenge of working with seriously ill patients, and sometimes great treatment success. Critical care also encompasses a complex mixed workforce: some work in closeknit teams, while others work in disparate groups and across multiple areas, and with less of the above support mechanisms. In short, each setting provides challenges and opportunities, and there may be no one-size-fits-all solution. Researchers are acknowledging the complex dynamic factors that influence workplace wellbeing, burnout prevention and resilience.

Management strategies often focus upon the healthcare professional managing their stress at work, but it is important not to focus solely on a “fix the individual” approach. There is emerging evidence about the nature of work, and how an individual can be impacted by their team, their environment, and by the larger healthcare system. These insights suggest that wellbeing will only be achieved when we also address the larger system, and address the myriad factors that create and sustain harmful behaviours and dynamics in organisations. This booklet considers these factors with particular reference to critical care. Chapter one gives an overview of the psychology of workplace wellbeing, helping us to identify the foundations for better wellbeing at work. Chapter two reviews the current research in critical care to help better understand the prevalence of psychological concerns such as stress, distress, and burnout. Chapter three explores the individual and the wider consequences of

sustained poor psychological wellbeing in the workplace. Chapter four examines why staff in critical care might be at particular risk, and outlines some of the signs of compromised workplace wellbeing. Chapter five outlines possible strategies, at an individual, departmental and organisational level. Chapter six details pertinent worldwide resources, and provides case examples. Chapter seven explores career pathways and considers risk-reduction across the lifespan. Finally, the booklet provides some recommendations and identifies areas for further research. 2 Source: http://www.doksinet Chapter One: A Psychological Understanding of Workplace Wellbeing Key Points:  Psychological wellbeing is multi-faceted  In the workplace, it is influenced by individual differences (such as personality and coping style), job design, colleagues and team, management and leadership, and the wider organisation  Promoting psychological wellbeing is about the balance between positive factors or

resources and negative factors or demands.  Burnout is one of the detrimental psychological effects of imbalance between workplace demands and resources. Work is central to the lives and wellbeing of most people, and is important in maintaining and promoting mental health. What is Wellbeing? Broader wellbeing is complex, dynamic and multi-faceted, and as such as relatively hard to define. Kevin Daniels4 describes the core components of wellbeing as follows: Hedonic - the absence of sustained distress, and the presence of happiness and satisfaction in all areas of life. Eudemonic - the experience of agency or control: being able to live by your morals and values, and having meaning and purpose. Physical – personal functionality or ability. Social connections – relationship quality and ‘fit’ for your needs. The foundations of workplace wellbeing Below is an outline of the foundations of workplace wellbeing. A sustained imbalance, change or concern in any of these areas may

lead to compromised workplace wellbeing and symptoms such as burnout, distress, or stress. The individual’s own psychology Examples of these include concept of self, personality, coping style and emotional regulation (i.e the use of intelligent kindness has been considered as an appropriate method for coping), emotional intelligence, self compassion and self care. The job itself This is the physical and emotional demands of work. These incorporate role clarity, workload and schedule, control, adequate skills training and development. It includes whether there is sufficient stimulation and reward, a career pathway and the opportunity for career development. A sense of meaning, belonging, emotional labour, time for reflection, recovery and making sense of work are also key job factors. Workplace relationships: 3 Source: http://www.doksinet Peer Relationships. This includes both individual relationships, but also an understanding of the factors that affect the social psychology of

groups. Relationship with the manager Good leadership is one of the key factors the influences wellbeing at work5. This includes how leaders and team members work together to provide an atmosphere of psychological safety (a learning environment where mistakes can be explored). This also includes good communication, good team work, strong and identifiable team values, and fairness. This is otherwise known as the psychological contract. The organisation The overall culture and norms of the organisation can have a substantial impact on wellbeing: especially in the selection, training and support of good managers and leaders. The Individual The Job Overall department/ organisation Figure 1: foundations of experience of work Relationship with manager Relationship with peers The literature regarding the workplace predictors of burnout is summarised by the Health and Safety Executive’s 20086 document. Burnout is strongly predicted by personality variables and by the tendency towards

expressions that include negative emotion. However job stressors such as role conflict, ambiguity and workload are even stronger predictors of burnout. Psychological Distress: Understanding the underlying psychology of compromised workplace wellbeing Simply put, psychological stress can be defined as a situation in which demands exceed resources. Brief or low level stress may be perceived as a challenge or motivation, however sustained and excessive stress may lead to psychological distress. At the more severe end of the spectrum insomnia, fatigue, irritability, anxiety, traumatic stress, depression and suicidal ideation can develop. The management and promotion of workplace wellbeing is a balance between the multifaceted demands of work and the inherent rewards of work.7 For many adults, work demands are a major contributor towards feeling stressed. Due to increasing expectations, longer hours, and a perceived lack of workplace support, work-related stress has increased over the last

few decades. One such focus has been the recognition of a specific work4 Source: http://www.doksinet related psychological distress, burnout syndrome (BOS). This has become common worldwide, but is especially reported among members of high-stress high-stakes professions: firefighters, police officers, teachers, and all types of health-care professionals. When demands and the resources to manage those demands are out of balance, reduced workplace wellbeing can occur. This manifests in a number of ways, and may include temporary or prolonged disengagement, psychological distress (which may reach clinically significant thresholds, such as anxiety and mood disorders), acute or chronic stress, traumatic stress, compassion fatigue, burnout, and impaired physical health. In the UK, the Health and Safety Executive8 outline the management standards for the risk of workrelated stress. Importantly, they consider it the responsibility of the organisation to modify these factors:  demands -

workload, schedule and work environment.  control - how much say the employee has in their work  support - from the organisation, manager and colleagues  relationships - management of unacceptable behaviour and promotion of positive working  role – ensuring employees do not have conflicting roles.  change - how change is managed and communicated in the organisation. Similarly, Maslach9 has also outlined six specific areas of ‘job demand’: workload, control, reward, fairness, values and team factors. Human beings continually and automatically risk assess. We engage in behaviours to reduce risk, and mitigate anxiety. When feeling threatened in any work situation or otherwise, we release the stress hormones, cortisol and adrenaline, which support adaptive risk mitigating behaviour (known commonly as fight, flight or freeze). However, when feeling chronically threatened these hormones not only have a harmful physiological impact, they also result in neurobiological

changes so that the brain is chronically vigilant to threats. In addition, the higher the cortisol level, the harder it is to engage and be compassionate. This is because cognitive resources have been overwhelmed It has an impact upon our own individual psychology and behaviour but it also impacts the team. In essence, when your brain is planning for war, it does not attend to prosocial behaviour. Threats at work, whether through excessive demands, lack of resources, poor peer relationships, inadequate leadership etc, lead to threat-reducing behaviours, which further impacts others. Examples include:          Go into ‘doing’ mode and trying to be more productive Try to increase our sense of control through use of power such as bullying & coercion Making others feel fearful, including for their jobs Micromanaging Taking the path of least resistance Dissociating from our suffering (and from those around us) Blaming, scape-goating, and/or attacking

Using policy punitively Forming into groups & cliques Zimbardo (2007)10 has summarised the impact of poorly designed systems on human behaviours, and described how this toxic combination can result in social groups acting in inhumane ways 5 Source: http://www.doksinet towards each other. His work when applied to the NHS suggests that both individual departments, and larger organisations need to be aware of these risks and threats. Training and Culture of Healthcare Disciplines: Different disciplines have different social and cultural expectations, which influence the stress experienced at work. For instance, healthcare workers may assume that they must sacrifice their own health in order to maximize that of their patients. Understanding our own drives and motivations can help us to understand what may protect wellbeing and diminish burnout. Examples include:  Perfectionism and self-criticism rather than self-compassion  A bias towards external validation rather than

internal satisfaction, and a worry about being noticed more than being useful.  The presumption that all problems can be solved by simply “trying harder”, which would increase risk of emotional and physical exhaustion.  A pervasive culture that includes not availing of proper rest, poor eating and drinking habits, not obtaining regular exercise, and neglecting work life balance. Failing to look after ourselves ultimately reduces the quality of care delivered. Resilience Resilience is the ability of an individual, team or organisation to recover following a day-to-day demands, or following more significant adversity. In a longitudinal study of medical doctors investigating poor outcomes after stressful events, personal factors that predicted resilience included personality, previous adversity, and coping strategies; whereas organisational factors included workload, hours and rotas. Accordingly, we need to appreciate that it is the interaction of the individual and the

organisation that predicts resilience, rather than merely an individual characteristic.11 Expectations of coping: The emotional demands of work affect the psychological impact of work. In human service jobs such as healthcare, the emotional labour of our work requires skills in emotional regulation. Research suggests those who need to engage in “surface acting” (a suppression or generation of emotion to manage the social rules of the situation) are more likely to experience burnout12. A good example is the doctor required to put aside his or her feelings every time he or she breaks bad news. The personal beliefs and the social rules about suppressing feelings, and the perceived benefit to the family is an example of the complex interplay between individual and social psychology. Burnout: Burnout is one example of the psychological sequelae of reduced wellbeing at work. In the field of critical care, burnout has garnered much attention. Perhaps we have an interest in burnout

because it seems to provide a diagnosis, but in fact it is a syndrome. Freudenberger13 was the first to propose it as a concept, but Christina Maslach developed the concept further, arguing that it is one end of a continuum, rather than a diagnostic category. She conceptualises it as the opposite to workplace engagement and as an indication of systemic and organisational factors interacting with the individual. Indeed the Maslach Burnout Inventory14 is the most widely used burnout measure in 6 Source: http://www.doksinet the field, but it is intended it as a measure of the organisation, not as a diagnostic tool for the individual. “Burnout is one end of a continuum in the relationship people establish with their jobs, and stands in contrast to the opposite pole of engagement, in which people experience energy, involvement with their work, and feelings of effectiveness” (Lieter & Maslach, 200915) “People do not simply respond to the work setting; rather, they bring unique

qualities to the relationship. These personal factors include demographic variables (such as age or formal education), enduring personality characteristics, and work-related attitudes. Several of these individual characteristics have been found to be related to burnout. However, these relationships are not as great in size as those for burnout and situational factors, which suggests that burnout is more of a social phenomenon than an individual one”. (Maslach 200116) Maslach conceptualised three main components to the experience of burnout: Depersonalisation - a disconnection from the relationship of caring for the patient, family, and colleagues. Emotional exhaustion - a feeling of having nothing left to give, and may be considered in relationship to compassion fatigue. Lack of professional accomplishment – feeling ineffective in relation to work. To understand it in the context of critical care, we should appreciate its complexity, its connection to engagement at work, and the

heavy emotional labour of our work. Chapter two considers the prevalence and scope of burnout syndrome and other psychological morbidity in critical care staff, and chapter four explores why critical care staff are at particular risk. 1.4 Summary It is important to consider the psychological sequelae of problems at work. It is also important to acknowledge the complex and dynamic factors that contribute towards workplace wellbeing. This understanding could help us to design and maintain workplaces that promote and sustain workforce wellbeing. 7 Source: http://www.doksinet Chapter Two: The prevalence and scope of psychological morbidity in critical care staff– how much of a problem is it? Key Points  Most research examining the prevalence of psychological morbidity in critical care staff have largely focused on burnout (BOS)  Prevalence of BOS ranges from 4-60%  Studies are largely outside the UK and vary in scientific rigour  Post Traumatic Stress Disorder ranges from

18-24%, and 10-25% depression Working in an intensive care (ICU) can be especially stressful due to the high patient morbidity and mortality, challenging daily work routines, and regular encounters with traumatic and complex ethical issues. This near continuous and excessive stress can rapidly accelerate when caregivers perceive that there is insufficient time or limited resources with which to properly care for patients. As such, studies have shown critical care professionals to have one of the highest rates of BOS 17 and there is increasing international literature documenting the prevalence of BOS across all professional groups within intensive care. Yet there is a paucity of data from the UK As discussed in chapter one, the most commonly used scoring system is the Maslach Burnout Inventory (MBI). This defines burnout as having three different aspects: emotional exhaustion, depersonalization (negative or cynical attitudes towards patients), and loss of feeling of personal

accomplishment at work. These may be presented individually or collectively giving an overall prevalence of burnout syndrome. Table 1 gives a summary of recent studies of prevalence of psychological distress in critical care staff. Table 1 A Summary of Studies of Burnout Syndrome and psychological distress in Critical Care Staff (adult staff unless stated otherwise) Principle author Country Population Psychological distress Meynaar 201618 Netherlands 4.4% BOS Colville 201519 UK Teixeira et al 201320 Portugal N=272 Physicians Paediatric critical care N=120, physicians and nurses N= 300, physicians & nurses Czaja et al 201121 USA Paediatric Critical care nurses Merlani et al 201122 Switzerland N=3052, physicians & nurses 82% any psychological morbidity 68% one symptom+ BOS 29% BOS Verdon 200823 Switzerland N=91, nurses 28% BOS 8 61% one+ BOS 18% PTSD 31% BOS Source: http://www.doksinet Mealer et al 200724 USA N=351 nurses Poncet et al 200725 France

N=2392 nurses Embracio et al 200726 Coomber (2002)27 France N= 978 physicians UK N=627 Physicians 24% clinical PTSD in ICU nurses 33% BOS 46% BOS 25% depression 30% psychological distress (General Health Questionnaire) 10% depression Nurses: Compared with other specialties, critical care nurses more commonly experience BOS28. In critical care nurses, the most common symptom of BOS is emotional exhaustion (73%), followed by a lack of personal accomplishment (60%) and depersonalization (48%)17. The prevalence of BOS in critical care nurses varies by department. Nurses who reported the highest prevalence of BOS among their colleagues were also more likely to have BOS themselves. Therefore, units with a negative working culture might harbour a “contagion effect”29. Physicians: Prevalence studies that have focussed on critical care physicians have rates of BOS ranging from 4 to 46%. Within paediatric critical care this figure may even be higher with a 71% prevalence of BOS, more

than twice that of general paediatricians.(REFERENCE?) From the United States (US), Medscape’s annual survey of physician wellbeing30 consistently demonstrates critical care physicians have the highest prevalence (55% in 2016) and severity of BOS, in comparison with other specialties. The relative shortage of critical care physicians and the demands for overnight ICU coverage likely exacerbate BOS. High levels of burnout are often ascribed to treating dying patients However, in a recent Portuguese survey (2016)31 comparing burn out rates between clinicians in palliative care units and intensive care they found that 31% of the clinicians working in ICUs had a high level of burn out (like other studies). By contrast, in palliative care only 16% had BOS In 2002 a postal survey of all members of the UK Intensive Care Society32 found that one in three ICU doctors appeared distressed using a general health questionnaire and one in 10 was depressed, although this was no greater than other

specialities. There has been no more recent data on prevalence within UK Adult critical care: either medical or nursing. There is a paucity of data on the prevalence of BOS in other critical care health-care professionals, such as social workers, physiotherapists, psychologists, occupational health professionals, or speech and language therapists. This may be due to such individuals working in small numbers or isolation in units. There are methodological issues that should be considered. Firstly, there is inherent bias in survey data. Clinicians with more distress could be more likely to respond or social desirability bias may play a role. On the other hand, individuals with severe PTSD or BOS may be less likely to participate due to avoidance or apathykey features of these syndromes. In addition, Maslach designed the burnout Inventory to measure systems and organisations, and not to provide a diagnostic tool. BOS is not the only way to measure work-related psychological distress.

Future research could broaden the range of psychological symptoms measured, explore how these change over time, and ascertain the unique demands and resources relevant to critical care clinicians. Without this we will not be able to protect psychological wellbeing, and nor will we deliver the best care for patients 9 Source: http://www.doksinet 10 Source: http://www.doksinet Chapter three: The impact of reduced workplace wellbeing Key Points  Reduced workplace wellbeing impacts the clinician, team and patient  Personal consequences include exhaustion, worry, stress, poor decision making, pessimism, and feeling disconnected  Impact on teams includes reduced team morale, poor communication, and negative emotional contagion  There are well described implications for patient safety and patient experience Staff wellbeing is a personal and organisational problem, especially when close working relationships are essential for delivering safe and reliable patient care.

Critical care workers are at particular risk of exhausting their own emotional reserves and neglecting their own personal needs. Problems occur when the pattern is continually repeated. Stress and burnout are linked, and the symptoms of burnout are often similar to those of depression.(3) The UK Health and Safety Executive estimates that in 2013-2014 there were 487,000 cases of workrelated stress, anxiety and depression and the cost to the economy, in lost productivity, was estimated at £11.3m Within the Health Service there are additional issues of ‘competitive presenteeism’ whereby people feel unable to take time off work. This is particularly true in the early stages, because of the fear that patient care will be compromised and that others will be required to assume their workload. However well-intentioned, these behaviours can have a negative impact Tables 2 and 3 illustrate some of the consequences of compromised workplace wellbeing. Possible solutions are outlined in

Chapter Five. Table 2: Personal Consequences of work-related stress Cluster Burnout Poor sleep Depression Specific consequences and symptoms Emotional and physical exhaustion. Disinterest or disconnection with patients and families A feeling of being unable to achieve Increase in anxiety and stress. Unable to ‘switch off’. Altered circadian rhythm through shift working. Altered dopamine and serotonin levels. Exhaustion and chronic fatigue Poor decision making, cognitive difficulty Negative thoughts about self, self doubt Negative thoughts about the future Low mood Low satisfaction Pessimism, guilt Lack of interest Sleep and appetite change Suicidal ideation 11 General Consequences across domains Poor decision making Low self confidence Emotional lability Poor sleep Poor eating habits Disengagement at work Disengagement at home & in personal interests Lack of engagement with family No time for family or friends Poor working relationships Avoidance Poor coping strategies-

e.g nicotine, drug or alcohol excess Poor self care Source: http://www.doksinet Lack of confidence Hypervigilance - “on edge” Poor sleep, appetite Chronic worry Anxiety Catastrophic thinking Poor decision making Focus on details and perfectionism Aggression Hyperarousal Re-experiencing of traumatic memories (experienced as if in the here and now) Post Traumatic Stress Emotional blunting Avoidance Dissociation Increased muscle tension, Sustained poor postures, Fatigue and poor sleep Musculoskeletal/health Neck and back pain, headaches. complaints Susceptibility to GI complaints or ‘flu/colds’ Worsening of a pre-existing chronic health condition Table 3: System and Patient Consequences of work-related stress 12 Inability to recover (low resilience) Reduced immunity Absenteeism Presenteeism Source: http://www.doksinet Examples Patient Safety & Suboptimal patient care Poor communication. Risk-taking behaviour or conversely apathy / disinterest Higher rates of medical

errors Inability to handle cognitive load Higher standardized mortality rates* Higher healthcare infection rates Lack of discretionary effort / extra role performance Higher absenteeism/ staff turnover Moral and ethical distress. Lack of empathy. Disillusionment or cynicism. Inability to feel happy or satisfied. Development of a distant or indifferent attitude towards patients and colleagues. Emergence of negative or unprofessional behaviours. Risk-taking / apathy Self-doubt or lack of confidence. Impaired decision-making. Early retirement and reduced service (1) Absenteeism Higher staff turnover Poorer communication Increased incivility Not meeting deadlines/completing other expected roles & responsibilities. ‘Contagion’ effect amongst colleagues. Reduced team cohesiveness Poor job satisfaction. Greater challenges to recruitment. Lack of engagement Compassion Fatigue Depersonalisation Reduced clinical effectiveness Economic impact Wider impact on colleagues (increase in

system ‘strain’) and strained professional relationships. Negative working culture/ Reputation of organisation Dewa CS, Jacobs P, Thanh NX, Loong D. An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC Health Serv Res 2014;358:254 doi:10.1186/1472-6963-14-254 pmid:24927847 Point of Care Foundation. Schwartz Rounds https://wwwpointofcarefoundationorguk/ ourwork/schwartz-rounds/ Bianchi R, Boffy C, Hingray C, Truchot D, Laurent E. Comparative symptomatology of burnout and depression. Journal of Health Psycholpgy, 2013; 18(6):782-787 Moss M, Good VS, Goazl D, Kleinpell R, Sessler CN. A Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Health-Care Professionals. Am J Respir Crit Care Med 2016; 194(1) 106-113 13 Source: http://www.doksinet Chapter 4: Risk factors in critical practitioners; recognition and diagnosis care Key points:  A number of factors place critical

care workers at increased risk of psychological work stress (but many of these may also be found in other areas of medicine).  Individuals with avoidant coping strategies are more at risk  Aspects of the clinical work, job design, team related factors have also been researched  Individuals may recognise warning signs of burnout in themselves using the symptom list  There are standardised measures to help recognise these problems in the individual and the team RISK FACTORS In chapter one, the general enablers and risk factors for workplace wellbeing are discussed. A number of risk factors for workplace stress and burnout have been identified in research specific to critical care. Although, the data is not comprehensive, the following may act as specific antecedents to burnout and psychological distress in critical care practitioners: Individual factors  A tendency towards avoidant coping strategies of the individual member of staff33 Job design factors  Too much

responsibility relative to seniority and experience  Lack of recognition for work effort  The intensity of on-call duty  Absolute workload, although this is often mitigated as a risk factor when paired with adequate resource 34 Patient related  Conflict with patients and relatives; complaints  End of life issues and the process of withdrawing treatment35  Lack of control in decision making – particularly pertinent to nursing staff who experience moral distress when treatments are applied that they perceive to be futile  Speed of patient turnover36  Moral distress37 Team related  Relations with senior staff, especially management and incongruent leadership style38  Conflicts with colleagues; insufficient workplace civility 39  A vicious cycle of staff turnover  Emotional contagion- or the social psychological impact of burned out colleagues upon the rest of the team40 Of note, there is no clear research linking work hours, or number of ICU beds. By

examining the six specific areas of ‘job demand’ (modelled by Maslach) as they pertain to the critical care environment, it is possible to understand why healthcare in general, and critical care 14 Source: http://www.doksinet practitioners specifically, may experience the “perfect storm” of workplace stress- these are outlined in Table 4. Table 4: Maslach’s six specific areas of job demand with critical care examples Job risk factors Workload Critical care example Emotionally burdensome nature of caring for critically ill patients Control Traditionally top down leadership culture and practices. Decision maker hierarchy is problematic in some senior staff Poor recognition for demanding work – ‘Reward-effort imbalance’. Social reward more motivating, but patient feedback /gratification can be limited in ICU. Relatives often angry and staff blamed Compared to other departments: heavy patient load, high end-oflife burden Compared to colleagues: lack of transparency

in consultant job planning, pay banding inconsistencies, antisocial hours Incongruence between values espoused by leadership versus on the ‘shop floor’ Inadequate material resources to deliver optimal care Lack of trust = loss of psychological safety Breakdown of team support as units become larger and caseload more complex; conflict and workplace incivility, disruptive visiting teams Reward Unfairness Values Team Some individual risk factors are non-modifiable. These can include gender, marital status and personality traits. However, they are worth highlighting so that these individuals recognize that they may be vulnerable. By far the more modifiable risk factors are those within the job and wider system. For example, we may not be able to modify the frequency of end of life issues but resources can be provided e.g ensuring no staff member is exposed excessively to direct end of life care We can also promote peer support groups, participative decision-making, role clarity

for nurses and space for debriefing after a patient’s death. Additional strategies are outlined in chapter five RECOGNITION41 Burnout and work-related stress can be insidious. They are often difficult to identify, and therefore significant psychological distress and underperformance may have grown, undetected for years. Initial warning symptoms may include:  Increased or over-commitment to goals  Exhaustion and lack of enthusiasm for work  Reduced commitment and detachment from patients and the whole team  Emotional reactions – low mood, blaming, anger, cynicism  Reduced cognitive performance, motivation, creativity, judgement  Flattened emotional life, social life, intellectual life  Psychosomatic reactions including sleep disorders  Despair and anxiety 15 Source: http://www.doksinet Clinicians experiencing stress may express an intention to leave their current post, but this is more common in professional groups with more options. Burnout is also a team

phenomenon: the emotional contagion of burnout within team is well described. Accordingly, there are team metrics such as the HSE Management Standards Tool and Maslach’s Burnout Inventory. Unfortunately, however, there are comparatively fewer metrics by which to assess the team, compared to the individual. As a result, staff turnover and sick days are used as surrogate measures. ASSESSMENT Chapter three outlines the range of psychological consequences of work-related stress and its symptoms. As outlined, burnout is one psychological consequence of work-related stress. It is not a recognised psychiatric disorder, but instead it is best understood as a syndrome. The burnout construct is context-specific i.e it relates to the workplace Although it eventually can impact on other areas of life, it does not by itself have the pervasive impact of a psychiatric disorder. At later stages along the burnout continuum, symptoms may be so severe that overlap syndromes are diagnosed such as

depression and anxiety. These require professional assessment and management. (refs 2011; 2015) Workplace wellness is measurable and many healthcare organisations are calling for it to be included as a key performance indicator. The concepts of burnout and engagement, which are respectively negative and positive psychological states in relation to work, are measurable and well-defined constructs. Why assess for the presence of occupational stress? 1. The legal requirement - under the Management of Health and Safety at Work Regulations employers should assess the risk of stress-related ill health arising from work. 2. There is a business case – detrimental effects on patient care such as patient satisfaction, patient safety, healthcare associated infection are costly as well as the associated economic burden of staff turnover and absenteeism. 3. There is a humanitarian case – an ethical obligation for healthcare leaders to care for the carers who perform emotional and burdensome

work 16 Source: http://www.doksinet Table X gives some of the many validated psychometric measures related to workplace wellbeing. In 2008 the NHS commissioned a review of workplace stress measures and concluded that there is no single preferable measure42. Assessment Area Potential Measures Individual Wellbeing General Health Questionnaire * The Warwick Edinburgh Wellbeing Scale * Utrecht Work Engagement Scale - engagement is thought to be the opposite of burnout* Professional Quality of life measure (The Pro-Qol) includes BOS, compassion fatigue and compassion satisfaction Individual Psychological Distress Psychometric measures of distress should be used by a trained professional, and include the following examples: Measures of depression: Beck Depression Inventory*, Hamilton Depression Rating Scales, PHQ-9 Measures of anxiety: GAD-7, Beck Anxiety Scale, State Trait Anxiety Scale Measures of PTSD: Impact of Event Scale-Revised (IES-R) Team Measures of Burnout: Maslach

Burnout Inventory, Oldenburg Burnout Inventory, Copenhagen Burnout Inventory * Health and Safety Executive Management Standards Tool43 Maslach Burnout Inventory- originally intended as a team measure NB: Self report questionnaires should not be considered as the only indicator, and consideration should be given as to is who is carrying out the assessment (psychologist, manager, other) including the motives for assessing staff wellbeing. 17 Source: http://www.doksinet Chapter 5: Strategies for improving workplace wellbeing, and reducing risks Key points  When improving wellbeing at work there is no magic bullet  It is preferable to consider a preventative approach, involving the individual, job design, environment, team, and management/ leadership.  Models for improving workplace wellbeing have been outlined by The Institute of Healthcare Improvement (IHI) and the Health & Safety Executive (UK) Chapter one outlined the foundations for wellbeing at work (figure 1). Any

sustained imbalance in these key factors increases the likelihood of reduced workforce wellbeing. In this chapter we outline strategies for promoting workforce wellbeing within critical care and other healthcare settings. Our hope is that this is pragmatic and can apply across the range of disciplines working in critical care. Each system, including those in healthcare, will vary according to its needs and culture, and it is important to consider what combination of interventions or management strategies may be required. It is advisable to conduct an organisational health review to ascertain the specific needs, strengths and weaknesses of any area. In the context of critical care, this may relate to the whole of critical care, or to specific teams within the wider context of critical care. As outlined in chapter one, the Health and Safety Executive identified the components of workrelated stress, and consider it the responsibility of the organisation to modify these factors.

Additionally, the National Institute for Health and Clinical Excellence 2015 guidelines, Workplace policy and management practices to improve the health and wellbeing of employees44, highlights the following: • • • • • • • • Promote leadership that supports the health and wellbeing of employees Explore the positive and negative effect of an organisations culture on wellbeing Health and wellbeing should be a top organisational priority Clear evidence that wellbeing links to outcomes including safety & mortality Leadership is key to enable and promote this Line managers (& their leadership style) have a great influence A proactive stance is required Utilise HSE Management standards A model for increasing ‘Joy in Work’ has been proposed by the Institute for Healthcare Improvement. They make a compelling case for improving workplace wellbeing as a key foundation of safe and effective care. In their white paper, Framework for Improving Joy in Work, they outline

how this aim is achievable by applying improvement science methodology and describe actionable domains for individuals, local leaders and the wider organisation. Many of these domains are identifiable in Maslach’s six areas of work as previously described, with the role of leadership being central to improvement. 18 Source: http://www.doksinet Healthcare workers experience a wide range of emotions in response to work, and these may range from normal workplace distress to significant psychological concerns. The intervention should match the concern, and be bespoke to the strengths and needs of the individual, team, or wider service. There is no “one size fits all”. Therefore, the following might be considered a list of potential enablers to individual, team and system wellbeing. This is not an exhaustive list The motivation for improving workplace wellbeing should be considered. The focus on workplace wellbeing cannot be driven by a desire to improve productivity alone.

Happiness naturally leads to improved productivity and patient care, but getting the most out of staff is different from getting the best out of staff. Strategies may be categorised in different ways: Primary strategies are considered preventative- a way of enabling positive workplace wellbeing. Secondary Strategies are considered responsive- a way of inhibiting further stress and restoring 19 Source: http://www.doksinet individuals or teams to a baseline level of functioning. Some secondary strategies may have a further preventative impact. 20 Source: http://www.doksinet Level of intervention INDIVIDUAL Potential Enablers or strategies Primary Strategies (Prevention): “Self-care” strategies may include          Self awareness and monitoring of possible symptoms of chronic stress Self preservation and self-care: whatever that looks like for the individual Healthy lifestyle: sleep, diet, exercise etc Time for self outside of work- including fun,

hobbies, holidays etc Sufficient “down time” to counteract the high stimulation of critical care Friends, family, social support Reflective space to share experiences of work/ psychologically debrief Self compassion Be aware of self criticism and negative bias in thinking “Career Care” strategies Personal development reviews including annual appraisals Regular one-on-one meetings with a manager Coaching and Mentorship Career pathway and advice: consider bespoke options Frank discussions: i.e can we expect all staff to continue to work at the same pace, or should this change with age and lifestyle? Building skills Training to include team, leadership and self-awareness skills eg. understanding the challenges and needs of others Wellbeing awareness and wellbeing skills management Secondary strategies: Staff who are starting to experience a reduction in their workplace wellbeing and may be at risk of further psychological deterioration may benefit from the following: Counseling,

psychological, or psychiatric interventions. These can be provided by employee wellbeing services, occupational health, Employee Assistance Programmes, or by local mental health services. The level of need depends upon the extent of the problem. This may include, but is not exclusive to:  Lifestyle advice (which may include advising time away from work)  Exploring coping mechanisms  Elucidating traumatic responses  Emotional regulation  Assertiveness training  Evidence based psychological therapies (Including, but not limited to Cognitive Behavioural Therapy, Mindfulness Based Cognitive Therapy, Interpersonal Therapies, Psychodynamic therapies). For serious mental health concerns, individuals may need a period of care under professional mental health services, which may also include prescribed medication. 21 Source: http://www.doksinet JOB DESIGN Job Design:  Adequate balance of job demands and resources  Include a review of how often staff are engaged in

activity they find meaningful  Including adequate opportunities for skills building  Task variety  Appropriate utilisation of skills and strengths / person-job fit  Adequate staffing and tools to do the job safely (GPICS standards)  Clarity of role  Clarity of expectations Personal development:  Opportunities for promotion and professional growth  Space for innovation and creativity. E.g projects such as research, education and quality improvement  Time for training, support and performance feedback from mentors  Support and training for mentors  Create ways to engage frontline staff E.g “genius hour”, where any member of staff can pitch a new idea to management Practicality of rotas/ work schedules  Allowing sufficient off-duty time such that workers can reflect, recover and reenergize.  Consider limiting the number of consecutive shifts worked  Limit the mix of days and nights  Manage schedules in collaboration with the workforce 

Maximize flexibility so that staff maintain some control over their work  Patient loads that reflect physical capabilities  Ensure work schedule keeps meaningful components of job eg heavy out of hours with sparse daytime commitment may reduce purposeful aspects. Cultural change Normalize the idea of staff wellbeing within job design Explicit measures to ensure sustainability over a 30 or 40 year career span Consider counter cultural changes in working patterns eg sabbaticals, modified work rotations Time off from work - facilitated in a way that staff do not feel judged or blamed CLINICAL APPROACH Review the management of complex patients and families.  Especially when goals compete, and there are disagreements about care plans  Outline goals, and share care plans.  Facilitate multidisciplinary team discussions  Encourage regular reflection on the impact of working with complexity and risk MANGEMENT & LEADERSHIP Burnout appears to be lessened where leadership

is seen supportive, collegial, and shares the same values as frontline clinical staff. It is also important that leadership is seen as “one of us”.1 Selecting for evidence of good leadership characteristics:   Clarity, consistency, predictability and fairness Emotional intelligence 22 Source: http://www.doksinet   Willingness to provide psychological safety Self-compassion and ability to act compassionately towards others Supporting high quality leadership Measures to support the sustainability, wellbeing and compassion of leaders All strategies considered under ‘individual’ should be available to leaders/ managers Coaching and mentorship for leaders Time limited contracts on clinical leads, clinical directors and senior nurses 360 degree feedback on leaders Consistent leadership approach - proactive and responsive; not just reactionary. Communication Clear team vision and values – identify the ‘shared goal’ A forum for listening to staff concerns –

‘’what matters to you?” Clear communication: “you said, we did, we will” type publications, newsletters etc Clear standard operating procedures, which staff have access to and understand e.g surge policy Recruitment Succession planning to ensure skill mix and corporate memory Values-led recruitment Adressing the issues causing high turnover eg properly designed exit interviews Measurement Measure staff wellbeing – demonstrates to staff that wellbeing is a priority. A regular “temperature test”- organizational health review within each department, with achievable focus, action plans and time lines Behaviours Adequate management of difficult behaviours observed within individuals or teams. Clear Dignity at Work and Grievance Policies. An awareness of systems psychology and how individual behaviour may be a reflection of team issues rather than “scape-goating” individuals. TEAM/ CULTURE Safety: wellbeing and safety are explicitly linked    Creation of

Psychological safety45 in teams: a culture of no-blame and constantly backed by explicit policy A culture of reflection and enquiry Structured communication tools and communication training Embed Wellbeing into the Department     Staff wellbeing considered in each relevant policy and promoting a culture where staff wellbeing is prioritized as the norm. Championing wellbeing matters every day- where there is consistency, rather than just “one offs”. A staff wellbeing group where staff can discuss matters relating to wellbeing. Wide representation, regular occurrence, actionable outcomes. Incorporate resilience and stress management into the workday E.g pre-shift pre-brief (models such as HALT) and end of shift check in 23 Source: http://www.doksinet Wellbeing as a Team Phenomenon Team days: an opportunity to develop relationships not just clinical skills Staff social activities: promote a sense of belonging Awareness of social/ group psychology in senior staff and a

willingness to work on this Allow time for the “informal organisation” such as social time, coffee room, acceptable social media Valuing the Team Meaningful recognition: Informally with simple gratitude, and formally through proper use of management support, appraisals, and celebration events Voice : allow time for employees to be truly heard. team meetings, utilising staff one- on-ones to consider factors influencing wellbeing A system of mutual support: peers, senior staff and mentoring programme. Reflection Reflective spaces for shared experiences. Routine debriefing is not recommended (such as Schwartz Centre Rounds46 and other similar models) Physical Environment A safe work environment is the bare minimum The optimal work environment should promote staff wellbeing Eg. good rest facilities, staff rooms, changing facilities, safe space for belongings Ergonomic design of bed space Consider noise and light levels Organisational Fairness displayed at all levels of the

organization level (Beyond A positive organisational culture with a clear mission critical care) Wellbeing should be a Quality Indicators for the organisation Visible display of behaviours consistent with organisational values by the Executive Team i.e ‘values congruence’ The story of the organisation told through media/ publications/ website Removal of bureaucratic policies which create extra demands and minimal patient benefit Promotion of physical health such as alcohol reduction, exercise, nutrition. Organization supported by government to prioritize staff wellbeing as the foundation of safe care There have been some studies of interventions within critical care, and these have been usefully summarised elsewhere47.         Psychological therapy (one-on-one and within a group)Skills development: time management, meditation, relaxation, self-care Split job with another area Reflective debriefing (Mealer, 2009; Colville et al, 2016 submitted) Culture of

discussing cases Psychological safety Team building Communication 24 Source: http://www.doksinet     Rota- pacing Ethical discussions Appropriate goal setting for patients Earlier family conferences There are novel and applicable concepts regarding practical coping strategies for healthcare workers: Purposeful imbalance “Work/life balance” is key to revitalizing, maintaining perspective, and “blowing-off steam”. However, “balance” is difficult to quantify, and open to interpretation. Instead we could strive for purposeful imbalance.48 Like a tightrope walker we are constantly making back and forth adjustments. It is actually the adjustments that keep you balanced, whereas standing still is when you risk falling. At times, work will entirely commandeer your schedule and dominate your mind This means that we must discipline ourselves to compensate later so that family can also (unashamedly) have its turn. Purposeful imbalance reminds us that balance requires

effort and deliberate strategies: you rarely achieve it by accident. Intelligent kindness One of the downsides of working in a system focused on rapidly curing disease is that there can be uneasiness with uncertainty and problems that take time to solve. The unease with death and dying can also lead to maladaptive coping. The case for intelligent kindness encourages healthcare workers to understand the complexities and the impact of their work, and to engage in protective strategies to cope, rather than defensive ones. This quote from Ballatt and Campling is especially relevant: “For it is easy to forget .the damage, the pain, the mess they encounter, the sheer stench of diseased human flesh.it takes energy to be in the right state of mind so as not to physically recoil and express disgust. It is common to say that this state of mind involves ‘professional detachment’, but it also takes courage and ‘human’ kindness.”49 It is important to recognise there is no single

solution for the promotion of workplace wellbeing, and in an ideal world potentially all of the strategies listed above should be considered. 25 Source: http://www.doksinet Chapter Six: Examples of best practice and case examples (UK and worldwide) Key Point     Better programmes to mitigate burnout and poor workplace wellness are needed Of the programmes that do exist, few are regular, widespread, or preventative and often viewed by clinicians as tokenistic As no single solution exists, resources may come from many jurisdictions. Resources and cases examples are listed in order to offer reflection and to share practical solutions Organisational Case Studies and Best Practice The authors conducted email enquiries across the English-speaking acute care medical world in mid2017. The following is based on feedback to the question “what is best practice for mitigating the risk of burnout and poor workplace wellbeing in critical care staff.?” From our survey, we found

that there appears to be little that is mandatory, national or regularly repeated. As a result, the first conclusion is that best practise is unsatisfactory Pertinent resources have been summarised in Table 5. However, due to the limited results from the survey, the authors would encourage dissemination and addition. There is much more that could and should be done Australasia has widespread interest in this topic, but efforts typically target trainee doctors rather than Attending Doctors/Consultants or other healthcare professionals. There are no obvious national initiatives in North America, possibly because the Unites States and Canada organize healthcare mostly by state or province. Typical North American resources centre on referral to external counsellors rather than anything “in house”. Fortunately, however, these can be accessed free of charge through provincial/state health boards or via medical/nursing unions, and do not have to be reported. Medical trainees can access

these same resources, but many medical schools also have Offices of Wellbeing (staffed by full-time secretaries and which include several faculty and an Associate Dean). Unfortunately, these resources do not appear to be offered to, or accessed by, Consultants/ Attendings. In Wales, some health boards now have appointed heads of employee wellbeing. There are also selfreferral based psychology and counselling services for healthcare professionals This also exists across the rest of the UK, but is less widespread. Deaneries often outsource psychological therapy for trainees. Some hospitals/programmes have made efforts including educational days, mentorship programmes, and efforts (both formal and informal) with the stated goal of making staff feel engaged, valued and supported. The Point of Care Foundation is a UK based organisation that has been researching staff experiences, and produces extensive material aimed at improving that experience. Typically, health delivery organizations,

including the NHS, appear to respond in a reactive rather than proactive way. Sometimes they only intervene when the situation has become very disruptive, or has resulted in suicide. If there is an effort to tackle the subject then it is often seen as contrived 26 Source: http://www.doksinet For some staff there is a perception that they are compelled to attend employee wellbeing services, more as an exercise in ticking-the-box rather than for genuine benefit. As in other jurisdictions, counselling retains the stigma of failure, shame or weakness. For many these resources only come into play after problems have been identified, rather than as anything preventative or regularly scheduled. For many organisations it is often the symptoms (ie anger, frustration, turnover) rather than the cause (stress, workload) that is targeted. As a result, whether fair or not, it seems that efforts are concentrated most on staff who are perceived as vocal or disagreeable. Unfortunately, this means

that those who have become withdrawn or isolated may not be noticed. In short, administration is perceived as not having done enough Case Examples of Good Practice: Intensive Care Society, UK The Intensive Care Society (ICS) has prioritized Burnout and established a national collaborative. This will include both a long-form traditional position statement (to be aimed towards the Journal of Intensive Care) and a magazine style resource (to be forwarded to all Intensive Care Units). The ICS has also organized a day for education discussion and reflection (http://bit.ly/2oNhfXp) Bristol, UK -The SPEaC Happy App A group of NHS consultants developed an app to assist with employee engagement and communication. Users can log in and leave feedback or comments about the team, including frustrations or positive experiences. Results are reported in real time and can facilitate the resolution of problems, in essence using feedback to drive improvement. Staff feel valued, have improved morale and

local engagement is enhanced. Belfast, UK The Belfast Health and Social Care Trust has shown organisational commitment to staff wellbeing through its ‘bwell’ campaign. Part of this includes the ‘bwell’ website and app which staff can access at home. Preventative strategies for mental and physical ill-health are highlighted and staff events are organised through the ‘Here4U programme’. Cardiff, UK Cardiff Critical Care Unit has employed in-house psychological services for staff since 2005. The role is a 50:50 split in workload between staff and patients, and also covers the staff of the paediatric critical care unit. The current programme is led by one of the authors of this supplement, Dr Julie Highfield, Consultant Clinical Psychologist, which she describes as follows: Our mission is: Embedding psychological care in critical care. Our Vision is: The experience of critical care has minimal psychological burden, on patients, relatives & staff. Our Strategy is: A visible

psychological care model, shaping the care of patients and relatives, supporting the compassion of staff. Strategy Example interventions Ask and formulate Conducting organizational health review using qualitative quantitative methodology. Actively responding to the daily concerns of the staff group 27 and Source: http://www.doksinet Engage Prevent Support and value Presenting a psychological formulation to the directorate team and clinical board team Chairing a staff wellbeing group, leading staff to develop their own initiatives Being embedded and visible- working clinically alongside staff to bear witness to their experiences Working directly with the management to build long term strategies Contributing to leadership on the unit, by building and supporting those in leadership roles Creating safe spaces for reflection- “Reflective Rounds” Team building events Team education on self care, and improving staff culture Education on humanizing the ICU, and working through

the difficulties that patient care provokes Offering psychological therapy and psychological first aid to staff Being available for 1-1 reflective debriefing Celebration events and employee awards Dr Highfield also emphasizes the need to be a role model and custodian of values, to demonstrate self-care, to nurture relationships, and to treat conversation as a “safe space” where both can share without judgment. She also tweets about staff wellbeing @DrJulie H The Australian Social Worker and self-described Wellbeing Specialist, Elizabeth Crowe (@Lizcrowe2) deserves mention as her social media presence has popularized the topic and because she has lectured widely on the topic. 28 Source: http://www.doksinet Table Five: Example International Sources of Support Region Aus/NZ USA Canada UK Europe Resource Description Beyond Blue Doctors Mental Health To improve mental/physical health, wellbeing, & work programme conditions of healthcare professionals. Focus on re-humanising

healthcare & reducing burnout Hearts in Healthcare in healthcare. Website with contacts for doctors, medical students, & Australasian Doctors Health Network their families. College of ICM Welfare Special Focus on advocating for wellness in intensive care Interest Group doctors at all levels (formed 2016). Homepage of Dr P Wible: advice, retreats, & resources Ideal Medical Care for physician wellness. Internet resource: Dr D Drummond offers tools, tips, The Happy MD one-to one coaching. Collection of free resources, to promote doctor Resident Doctors of Canada wellness during training & throughout careers. Our own group, producing documents to aid UK critical ICS Burnout working group care doctors. Award winning, free & confidential for doctors/dentists The Practitioner Health Programme with physical/mental health concerns. AAGBI Support and Wellbeing service Doctors’ Support Network BMA Doctors for Doctors For performance issues in both trainees and consultants

– recognising potential for burnout to impact on performance National Clinical Assessment Service Focused on bringing the humanity back to ICU, and Project Humanizing ICU (Spain) tackling burnout syndrome. 6.2 Individual Case Examples “It’s okay not to feel okay” Narrative stories can aid reflection, can normalize the discussion, and can suggest the myriad presentations of burnout. Below are a few examples, and we would welcome more We have striven to remove identifying information, though we hasten to add that no individual should ever be embarrassed or feel shame. A) A paediatric trainee gradually became increasingly tired, irritable. She then experienced a major loss of confidence following an unsuccessful clinical examination. Unfortunately this constellation of symptoms went unrecognized and was not addressed, including by her physician husband. It culminated in a full mental breakdown one year later. Since then, changes have included: 1. A sabbatical – both doctors

took time out, despite potential risk to their careers 2. Making time for regular exercise 3. Spending more time with family 4. Reconnecting with hobbies, so much so that she started her own baking business 5. Medications for mood and sleep 29 Source: http://www.doksinet 6. A full reappraisal of lives, relationship, and priorities 7. Psychological therapy B) A physician friend confided that she was feeling constantly tired and low in mood. She had gone through relationship breakups and had recently taken time off work. She was finding work exhausting, and was “losing the point of it all”. She was still at an early career stage and did not know how she would “keep this up”. Support mechanisms have included: Listening: she was listened to empathetically, non-judgmentally and without being immediately prescriptive. This was clearly difficult for her to talk about She had not confided in anyone before, and did not feel she could trust many people. Acknowledgement: it was

emphasized that she was far from alone, her experience was “real”, not “personal weakness” or something that she simply needed to “snap out of”. Empowering: the listener then recommended some resources – the local occupational health department, a psychotherapy service, and a professional careers coach. Maintenance: the listener kept in regular contact and some months later, she reported feeling better and finding joy in work again. C) A successful mid-career Intensivist had achieved all clinical and academic goals but was increasingly irritable, and impatient. He found himself less inspired to read and learn because “what’s the point” and was counting the years until retirement. He also felt that even if he learnt more it wouldn’t materially change the likelihood of his patient’s surviving six months hence. After a week of frustration with his assigned trainees, and on the back of two straight weeks without a break, he exploded and gave his trainees a public

dressing down. He was reported, accused of unprofessionalism, and told to meet with an Associate Dean and then a counsellor. Since then, he has made several changes. 1. A sabbatical 2. Making a point of listing three enjoyable/stimulating things he has done each day 3. Spending more time with family 4. Not multi-tasking but rather making efforts to be truly engaged rather than just present 4. Restricting time spent on emails, twitter, and television 5. Biking to and from work 6. Meditation D) A successful early 50s Intensivist had not found any case fascinating in years. He was also doing less teaching, less research, and was skipping meetings. He felt he was “not as sharp” and had wondered if this was because he was simply chronically sleep deprived, depressed, or even the early stages of dementia (something that afflicted his parents). In contrast to his early career, he was increasingly interested in material possessions and in maximizing his private work. His colleagues

recognized he was smart and capable, but found him annoying and cynical. They also secretly described him as self-centred, contrarian and patronizing. He has wondered whether he was depressed. While not actively suicidal he had even found himself wondering the best way to “end it all” if he were to develop dementia. Of note, he has just gone through an acrimonious divorce Six months on: He now appears much happier with a new partner. He has shared custody of his children, but believes the time is of higher quality. He deliberately books time off from work, rather than assuming this will happen ad hoc. He is drinking far less alcohol and has lost two stone in weight. 30 Source: http://www.doksinet E) A critical care nurse found herself increasingly irritable with colleagues. She was resentful of having missed out on a recent promotion. She found being in charge of her area on shift highly stressful, and would avoid certain duties where she could. Colleagues stated she was “over

sensitive” which increased her sense of vulnerability and isolation. After much contemplation she accessed employee wellbeing services. Following psychological therapy: She was able to reflect on the emotional load of her work, and recognise that she felt undervalued. She learned some techniques of managing the impact of the stress, and how to take time to practice more compassion towards herself. She approached her team leader and discussed her disappointment at being overlooked for promotion, and was able to set objectives to improve her skills. She has recently been promoted 31 Source: http://www.doksinet Chapter 7: From training to retirement: career phase & longevity Key Points  There are few longitudinal studies of burnout  Points of stress will occur throughout a career working in critical care. Some evidence suggests professionals earlier in their training or career are more likely to experience stress.  Practitioners need to be aware of the tools, support

mechanisms and resources that are available and how to access them.  Managing a healthy work-life balance over an entire career should be promoted and supported by employers. Maintaining positive wellbeing is a challenge for clinicians at all stages of their careers in intensive care and high-risk periods may be counter-intuitive. There may be particular stages of a career in which demands are higher: such as studying for examinations, applying for jobs, return from maternity leave or sickness absence, working towards promotion, or approaching retirement. There is some debate whether psychological wellbeing is relatively stable over a lifetime. There are few longitudinal studies on burnout.50 Shaufeli51 suggests that, at least in healthcare professionals, burnout seems to be stable, at least across 3 years. This stability may be indicative of the lack of change in work environments over time, or risk variables that are harder to modify, however many studies do not accurately

account for baseline levels of burnout. Shaufeli suggests that occupational burnout is more sensitive to context than context-free general levels of psychological wellbeing, including measures of depression and anxiety. Physicians There are high rates of psychological difficulties in young doctors, and problems that manifest later may initially present at medical school, for example as addictions52. There is evidence that medical students display high levels of burnout53 and that this is associated with higher levels of unprofessional conduct and suicidal ideation. High levels of support may be protective54 Burnout is common in medical trainees generally55. A 2011 study of 21 208 internal medicine residents in the USA found that 51.5% had at least one symptom of burnout56 Emotional exhaustion improved as training progressed, however, depersonalisation increased. Women reported more frequent emotional exhaustion and depersonalisation than their male colleagues. The prevalence of burnout

in UK intensive care trainees is unknown. Intensive care medicine in the UK does not have a disproportionate drop out rate from specialty training compared to other programmes, although the current programme only started in 2012. Potential reasons for high levels of burnout in trainees include high workload intensity, low levels of individual autonomy and interference with home life. The burden of assessment, career uncertainty, rota gaps, the frequency of training rotations and high student debt may also contribute. Trainees may persevere in the expectation that workload and levels of stress will improve once they finish training. In fact, transition to consultancy may be a particular stress point A study of the characteristics of individuals attending a confidential psychological consultation service for doctors and dentists in the UK found that younger adults (30-39 years) represented the largest age group attending the service57. Mentoring during transition to consultancy may be

particularly valuable as 32 Source: http://www.doksinet trainees leave the support systems provided by training, although involvement of employers in providing this has been patchy. Trainees may choose not to pursue a career in intensive career medicine because of potential for burnout. A recent UK survey found that poor work-life balance, burnout, and anti-social working patterns were the most common concerns when considering a career in intensive care medicine58. A smaller US study in 1996 described high levels of burnout in internal medicine intensivists citing discrepancies in job demands, responsibility overload, end-of-life issues, and interpersonal conflict as potential stressors59. Clearly stressors are not necessarily job specific and there is no definitive evidence that ICM is significantly different from other acute medical specialties in terms of exposure to stress. There appears to be a need for support and monitoring from a very early stage in doctors’ careers,

including access to help and increasing awareness of the vulnerability of doctors. Trainees experiencing burnout may be able to seek support from peers, friends, and family. Clinical and educational supervisors and faculty tutors should be able to offer support locally. At a deanery level, support is available from training programme directors and regional advisors. Less than full-time training can be useful. Health Education England is looking to develop enhanced support for trainees who have had an extended period away from work. Systems in place to recognise the trainee in difficulty may assist in identifying trainees with burnout and all GMC recognised trainers will have training on dealing with a doctor in difficulty. An open culture founded on mutual respect and trust is essential. Although welcome, it is unclear whether regional or national initiatives to reduce trainee burnout are effective. Other sources of support are listed in chapter six A study of 7288 US physicians used

the Maslach Burnout Inventory to identify burnout at different career stages60. They found that levels of burnout were lowest in the later stages of physician careers: 40.4% of those working more than 20 years were burned out compared with 505% in the early stage and 53.9% in the middle stage Physicians in the early stage of their careers had lowest career satisfaction. Whether this is generalizable to physicians, and particularly intensivists, working in the NHS is not clear and it is notable that those in the middle stage of their careers worked more hours with more on calls than those in the early stage. No large scale study has been undertaken in UK doctors to look specifically at age and experience as a factor in critical care burnout. A small 2017 multidisciplinary study has shown that longer working hours and reduced recovery times increased stressors in intensive care professionals, and the inability of individuals to reflect effectively on those is a significant factor61. Some

intensivists maintain a second specialty to facilitate cessation of work in intensive care as they near retirement. While this ‘winding down’ mirrors many other career arcs it is unusual to maintain a second specialty for this purpose. It is unclear whether the General Medical Council have considered physician wellbeing in their support for single specialty training programs. The increasing uptake of single specialty training in the UK suggests that some trainees are disregarding the variety that dual specialty training affords. Nursing and allied health careers Burnout is common amongst critical care nurses. In a European nursing survey, 42% of UK nurses reported burnout, the highest of all 10 European countries surveyed; the European average of was 28%62. The American Thoracic Society, in collaboration with the American Association of Critical Care Nurses amongst others, estimated the prevalence of severe burnout amongst critical care nurses as 25-33%.63 33 Source:

http://www.doksinet Younger nurses have been found to have high levels of burnout in a number of studies including a US study of over 1200 nurses64. A Swiss multicentre study examined burnout across the multidisciplinary intensive care team and found that burnout was inversely proportional to age and experience65. In Health Education England’s 2014 review of nurses leaving the NHS, stress and burnout were identified as particularly high in newly qualified nurses. Turnover rates were high in the first year of qualification and rose further during the second year of service before declining, with stress and burnout being significantly correlated with intention to leave.66 Up to 34% of newly graduated nurses are not registering to practice67. If the work environment is not supportive of the individual, the reality of the job and a mismatch in expectations may lead to frustration and disappointment, which can contribute to burnout. Increased psychological resilience may reduce the risk

of burnout and so there may be a role for developing resilience early in a career68. More experienced staff may have developed coping strategies and resilience. It may also be that the pressures of intensive care naturally select those with greater resilience to burnout: less resilient and burnt out staff may leave. Attrition rates of younger and less experienced staff may suggest a larger problem and exit interviews should be considered for all staff leaving an intensive care unit. Burnout is less prevalent among older nurses with studies finding that mature nurses have greater job satisfaction, productivity, and organisational commitment.69 However, specifically within critical care, increased years of experience of nursing staff is correlated with increased avoidant coping strategies70, which in turn has been associated with increased burnout. Developing Career Strategies Public Health England has examined strategies to deal with individuals who have or are at risk of burnout15.

There is moderate evidence that individual and small group approaches such as workshops, cognitive behavioural training and stress management are effective at dealing with stress and burnout. However, alongside the individual approach, changing organisational culture and working practices is often needed to provide effective and sustainable solutions. Professional organisations are also potentially useful sources of support Many employers provide confidential support services where staff are able to self refer, e.g Workplace Wellbeing Schemes. Medical staff have additional resources available to them, for example the National Clinical Assessment Service, which is able to provide an individualised ‘back on track’ plan for doctors, dentists and pharmacists who have had time off work and need assistance in their re-entry to the workplace. For more details, see chapter 4. Conclusion Burnout is multifactorial. Research suggests younger age and reduced experience are important risk

factors in physicians, nurses and allied health professionals. At an individual level, recognition of the signs of burnout and developing resilience in the early stages of a career may be helpful. Some factors such as culture and working conditions are difficult for individuals, particularly early in their careers, to influence. Support from others is required, and again the importance of supportive leadership must be emphasized. 34 Source: http://www.doksinet Part B: Recommendations (Chapters 8 & 9 thematic outline) The Intensive Care Society Wellbeing Working Group collated 100 recommendations for improving workforce wellbeing, and raked these according to evidence base and achievability. Though this exercise, the group recognised that underlying ethos to the interventions and strategies is relational: relationship to self through taking care of oneself; relationship to others in the team, and how we take care of each other; and relationship to the system, specifically how

systems mitigate risk and promote a healthy workplace environment, often via good leadership. THIS IS A BRIEF OUTLINE OF THE THREADS THAT WILL BE DEVELOPED FOR CHAPTERS 8 AND 9 Individual and peer-to-peer recommendations The top recommended individual interventions and strategies are: 1. Access to professional psychological help (counselling, psychological intervention or psychiatric intervention as appropriate) 2. Self care through a healthy lifestyle (good sleep, diet, and exercise) 3. Individual reflective space to make sense of experiences within critical care 4. Personal development and annual appraisal at work The top recommendations for peer-to peer/ team are: 1. Reflective spaces for staff communication to discuss spaces, for example Schwartz Centre Rounds 2. Team days as an opportunity to develop relationships 3. Multidisciplinary team discussions of patients Organisational Recommendations The top organisational and workforce recommendations were: 1. 2. 3. 4. 5. 6. Rotas and

work patterns that reflect differing individual needs at different career stages Career pathways and advice Coaching/mentoring Bespoke career pathways Workforce engagement events to build better insights into needs of individuals Health promotion e.g the Fatigue Working Group 35 Source: http://www.doksinet (Chapter 10 – pending) Chapter 11. What don’t we know yet? Signposting for next directions There is a growing interest in the psychological wellbeing of the workforce within critical care, however there are unanswered questions. What we know from the critical care wellbeing literature: We have prevalence data for burnout syndrome, and some other measures of psychological distress in critical care in parts of Europe and America, but not UK or Australasia. Individual factors that may increase risk for critical care staff include younger staff, and staff who utilise avoidant coping methods to manage stress. Critical care specific factors include the impact of pace, patient

turnover, difficult moral and ethical dilemmas, high exposure to end of life care, exposure to care which seems futile, hours of work and rota. Systems factors influencing this are: a workforce with high stress that strains relationships and this remains unchecked, the influence of management and leadership on these factors and other team dynamics which influence psychological safety. Research indicates that teaching non-avoidant coping strategies can help, but is limited in isolation Systemic interventions that mitigate risk factors in critical care and take positive approach to leadership and workforce engagement have also shown promising results. What we do not know 1. We don’t have clear UK prevalence data 2. We don’t understand the relative contribution of the risk factors (listed above), and there may be other factors we have missed 3. We don’t have longitudinal data or understand wellbeing and burnout over time 4. We have not tested interventions in randomised controlled

trials The next steps: 1. ICS State of the Art Survey The ICS State of the Art team have decided to run a survey of State of the Art 2017 attendees wellbeing using the Maslach Burnout Inventory, to generate burnout prevalence data 2. FICM Workforce Census The Faculty of Intensive Care Medicine run an annual workforce survey, and in 2018 will include measures of workforce wellbeing. 3. The Future More research to understand the greatest risk factors, as well as longitudinal research and trials of interventions are needed. 36 Source: http://www.doksinet REFERENCES 1 "The Worlds Biggest Employers". Forbescom Forbes Retrieved 31 July 2015 To do: 3,4 2 Lemaire JB, Wallace JE. Burnout among doctors British Medical Journal, 2017, 358 3 Royal College of Nursing Beyond breaking point: A survey report of RCN members on health, wellbeing and stress. 4 https://www.ueaacuk/norwich-business-school/people/profile/kevin-daniels 5 NICE NG13 (2015). Workplace health: Management

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Dynamics 2012;23:25–31 29 Bakker AB, Le Blanc PM, Schaufeli WB. Burnout contagion among intensive care nurses J Adv Nurs 2005;51:276–287 30 http://www.medscapecom/slideshow/lifestyle-2016-overview-6007335#2) 31 Martins Pereira S et al (2016) Compared to Palliative Care, Working in Intensive Care More than Doubles the Chances of Burnout: Results from a Nationwide Comparative Study. PLoS ONE 11(9): e0162340. https://doiorg/101371/journalpone0162340 32 Coomber et al. Stress in UK intensive care unit doctors British Journal of Anaesthesia 89 (6): 873±81 (2002) 33 Iglesias, M. E L et al (2010) The relationship between experiential avoidance and burnout syndrome in critical care nurses: a cross-sectional questionnaire survey, International Journal of Nursing Studies, Vol.47, pg30-37 34 Meynaar, I.A, JLCM van Saase2, T Feberwee3, TM Aerts4, J Bakker5, W Thijsse5 (2016 ), Burnout among Dutch intensivists – a nationwide survey. Netherlands Journal of Critical Care 35 Poncet MC1, et

alAm J Respir Crit Care Med. 2007 Apr 1;175(7):698-704 Burnout syndrome in critical care nursing staff. 36 Verdon, M. Merlani, P, Perneger, T, Ricou, B, Burnout in a surgical ICU team Intensive Care Med (2008) 34:152–156 37 Elpem, E.H et al (2005) Moral distress of staff nurses in a medical intensive care unit, American Journal of Critical Care, Vol.14, Iss6, pg53 38 Boyle, D.K et al (1999) Manager´s leadership and critical care nurses´ intent to stay, American Journal of Critical Care, Vol.8, Iss6, pg361 39 Riskin et al (2015) The Impact of Rudeness on Medical Team Performance: A Randomized Trial PEDIATRICS Volume 136, number 3, September 2015 ARTICLE Arieh Riskin, MD, MHAa,b, Amir Erez, PhDc, Trevo 40 Bakker AB, Le Blanc PM, Schaufeli WB. Burnout contagion among intensive care nurses J Adv Nurs 2005;51:276–287 41 Burish 2010 Burnout for Experts: Prevention in the Context of Living and Working 38 Source: http://www.doksinet 42 National Co-ordinating Centre for the National

Institute for Health Research Service Delivery and Organisation Programme Measuring and Assessing Organisational Culture in the NHS (2008) 43 Health and Safety Executive http://www.hsegovuk/stress/standards/pdfs/indicatortoolpdf Accessed 2017 44 National Institute for Health and Clinical Excellence 2015 guidelines, Workplace policy and management practices to improve the health and wellbeing of employees 45 Edmondson, A. (1999) Psychological safety and learning behavior in work teams Administrative Science Quarterly; Jun 46 Point of Care Foundation. Schwartz Rounds https://wwwpointofcarefoundationorguk/ ourwork/schwartz-rounds/ 47 Moss, M., Good, V, Gozal, et al An official critical care societies collaborative statement- Burnout syndrome in critical care health professionals: A call for action 48 Todd Duncan. Life on the wire: avoid burnout and succeed in work and life Thomas Nelson Nashville. 2010 49 Ballatt, J. , Campling , P. (2011) Intelligent Kindness: Reforming the Culture

of Healthcare 50 HSE: The nature, causes and consequences of harm in emotionally-demanding occupations (2008) 51 Stability and change in burnout: A 10-year follow-up study among primary care physicians Wilmar B. Schaufeli1∗, Gerard H Maassen2, Arnold B Bakker3 and Herman J Sixma 52 Marshall, J. (2008) Doctors’ health and fitness to practise: Treating addicted doctors Occupational Medicine, 58, 334–340. 53 Dyrbye LN, Massie FS, Eacker A, Harper W, Power D, Durning SJ, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA 2010 Sep 15;304(11):1173–80. Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and Suicidal Ideation among U.S Medical StudentsMedical Student Burnout and Suicidal Ideation Ann Intern Med. American College of Physicians; 2008 Sep 2;149(5):334–41 54 SA S, DB H, JD K, RR H. Burnout in medical students: examining the prevalence and associated factors. South Med J 2010 Aug

1;103(8):758–63 55 Thomas NK. Resident burnout JAMA American Medical Association; 2004 Dec 15;292(23):2880–9 56 West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA 2011 Sep 7;306(9):952–60 57 Garelick, A., Gross, SR, Richardson, et al (2007) Which doctors and with what problems contact a specialist service for doctors? A cross sectional investigation. BMC Medicine, 5, 26 58 Shah A, Linford S, Wallace F, Arulkumaran N, Wong A. Barriers to a career in intensive care medicine. JICS SAGE PublicationsSage UK: London, England; 2017 Apr 25;18(2):91–2 59 Guntupalli K, Fromm R. Burnout in the internist-intensivist Intensive Care Medicine July 1996, 22(7) pp 625-630 60 Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician Satisfaction and Burnout at Different Career Stages. Mayo Clinic Proceedings 2013 Dec;88(12):1358–67 61 Vandevala T, Pavey L, Chelidoni O, Chang N,

Creagh-Brown B, Cox A. Psychological rumination and recovery from work in intensive care professionals: associations with stress, burnout, depression and health Journal of Intensive Care 2017 5(16) 62 Heinen M M. et al (2012) ‘Nurses’ intention to leave their profession: A cross sectional observational study in 10 European countries’, Journal of Nursing Studies. 63 Moss M, Good V, Gozal D, Kleinpell R, Sessler C. A Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Health-care Professionals : A Call for Action. American Journal of Respiratory and Critical Care Medicine 2016 Jul 194(1) 64 Mealer M, Jones J, Newman J, et al. The presence of resilience is associated with a healthier psychological profile in intensive care unit (ICU) nurses: results of a national survey. Int J Nurs Stud 2012; 49:292–9 39 Source: http://www.doksinet 65 Merlani P, Verdon M, Businger A, et al. Burnout in ICU caregivers: a multicenter study of factors associated to

centers. Am J Respir Crit Care Med 2011; 184:1140–6 66 Health Education England (2014), Growing Nursing Numbers: Literature review on nurses leaving the NHS 67 Finlayson B, Dixon J, Meadows S et al. (2002) ‘Mind the gap: the extent of the NHS nursing shortage’. BMJ Sep 7, 2002; 325(7363): 538–541 68 Poncet MC, Toullic P, Papazian L, et al. (2007) Burnout syndrome in critical care nursing staff Am J Respir Crit Care Med. Apr 1;175(7):698-704 69 Hayes L J, et al. (2006) ‘Nurse turnover: A literature review’ International Journal of Nursing Studies 43 (2006) 237–263 70 Iglesias, M. E L et al (2010) The relationship between experiential avoidance and burnout syndrome in critical care nurses: a cross-sectional questionnaire survey, International Journal of Nursing Studies, Vol.47, pg30-37 NOTES ON REFs REF for chapter 3 REFERENCE with regard to Paediatricians rate of burnout Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfsaction with work-life balance among US

physicians relative to the general US population. Arch Intern Med 2012; 172: 1377-85 Additional reference on leadership – to be inserted in Chapter 5. LEADERSHIP Shanafelt TD, Gorringe G, Menaker R, et al. The impact of organizational leadership on physician burnout and satisfaction. Mayo Clinic Proceedings 2015;90(4):432-440 40 Source: http://www.doksinet Appendix: The Faculty of Intensive Care Medicine work programme The Faculty of Intensive Care Medicine (FICM) recognises that workforce wellbeing is both an individual and a wider organisational construct. Those working in critical care form a close knit, multidisciplinary team and all staff groups should be supported to ensure the unit culture promotes individual health and wellbeing. There will be times of stress for individuals often centred around caring for individual patients and families and also for the wider team. Through the Careers, Recruitment and Workforce committee, FICM is adopting a strategy based on

encouraging entry into ICM, maintaining a healthy professional and personal work life balance and then on into planning for retirement from full time clinical practice in ICM. Since its creation, the Faculty has collected workforce data and from 2018 it will determine a snapshot of the psychological health of the workforce and through longer term tracking using validated tools. The careers section of the Faculty website is being populated with information outlining the benefits of a career in ICM led by a designated Board Member with expertise in careers planning, promotion and support. This currently includes ACCP as well as medical information and is focussing on sharing of information eg anonymised job plans to illustrate how individuals may consider different patterns of working. A Faculty Board member also leads on workforce engagement and feedback. To date 6 workforce engagement events have been conducted (including in Wales and Scotland) involving multiple stakeholders in

conversations outlining their challenges and exploring ways in which these could be progressed. A report from the first 5 events will be released in early 2018 to highlight common themes and solutions. Additional work is taking place with other professional organisations eg the AAGBI to highlight the importance of good sleep hygiene and practices to facilitate safer night working. In 2017 the Women in ICM group was also established: coaching is being developed through this group as a means to expand the promotion of coaching and mentoring techniques into the wider workforce. Faculty focus for 2018 will be on promoting a healthy work life balance, with an Annual Meeting “Mind the Gap” devoted to exploring ways to use activities outside of work to promote resilience and maintain energy for a healthy ICM career. 41