Disconnection and Distress - criticalcarecanada.com DisDi… · 12 November 2019 Disconnection and Distress Woke up this morning. Went back to bed. C Parshuram ICU Clinician· Senior

12 November 2019

Disconnection and DistressWoke up this morning. Went back to bed.

C Parshuram ICU Clinician· Senior Scientist· Professor· BPWK mentee & colleague

I have no relevant (additional) disclosures.

for Dr. Afrothite Kotsakis

Christopher S Parshuram Department of Critical Care Medicine | Center for Safety Research | Child Health Evaulative Sciences | SickKids | University of Toronto

the Intensive Care Unit

important things happen (t)here ICU healthcare professionals are distinct performance is multi-facetted & varies ICU-user needs & ICU success are perceptions disconnection & distress are part of the journey


Death is a source of distressit’s understood, it’s reasonable, it’s expected.we worry when it’s not apparent.

the path ‘ending’ at death can also be distressing, and involves trade-offs that can be seen differently.


distress disconnectionmoral distress compassion fatiguestress / anxiety burnout post-trauma stress depression

bad stress & disconnection

work performance personal wellbeingemployee turnover

Colville 2017, Larson 2017

• Anxiety-Distress +VE association burnout

• Uncertainty about therapeutic benefit +VE-correlation to moral distress (p<0.001)

• attending mitigation strategies reduced burnout (and the effect may be minor)


grief = distress

872 families eligible, 23% RRInventory of Complicated Grief 19-items x 0-4 points = max 76

>30 complicated grief.

59% had complicated grief 6 months after the childs death

ARTICLE

JOURNAL CLUB

Complicated Grief and Associated Risk FactorsAmong Parents Following a Child’s Deathin the Pediatric Intensive Care UnitKathleen L. Meert, MD; Amy E. Donaldson, MS; Christopher J. L. Newth, MD, ChB; Rick Harrison, MD;John Berger, MD; Jerry Zimmerman, MD, PhD; K. J. S. Anand, MBBS, DPhil; Joseph Carcillo, MD;J. Michael Dean, MD; Douglas F. Willson, MD; Carol Nicholson, MD; Katherine Shear, MD;for the Eunice Kennedy Shriver National Institute of Child Health and Human DevelopmentCollaborative Pediatric Critical Care Research Network

Objective: To investigate the extent of complicatedgrief symptoms and associated risk factors among par-ents whose child died in a pediatric intensive care unit.

Design: Cross-sectional survey conducted by mail andtelephone.

Setting: Seven children’s hospitals affiliated with the Col-laborative Pediatric Critical Care Research Network fromJanuary 1, 2006, to June 30, 2008.

Participants: Two hundred sixty-one parents from 872families whose child died in a pediatric intensive care unit6 months earlier.

Main Exposure: Assessment of potential risk factors,including demographic and clinical variables, and par-ent psychosocial characteristics, such as attachment style,caregiving style, grief avoidance, and social support.

Main Outcome Measure: Parent report of compli-cated grief symptoms using the Inventory of Compli-

cated Grief. Total scale range is from 0 to 76; scores of30 or higher suggest complicated grief.

Results:Mean(SD)InventoryofComplicatedGrief scoresamong parents were 33.7 (14.1). Fifty-nine percent of par-ents (95% confidence interval, 53%-65%) had scores of30orhigher.Variablesindependentlyassociatedwithhighersymptom scores in multivariable analysis included beingthebiologicalmotherorfemaleguardian,traumaasthecauseofdeath,greaterattachment-relatedanxietyandattachment-related avoidance, and greater grief avoidance.

Conclusions: Parents who responded to our survey ex-perienced a high level of complicated grief symptoms 6months after their child’s death in the pediatric intensivecare unit. However, our estimate of the extent of compli-catedgrief symptomsmaybebiasedbecauseofahighnum-berofnonresponders.Betterunderstandingofcomplicatedgriefandits risk factorsamongparentswillallowthosemostvulnerable to receive professional bereavement support.

Arch Pediatr Adolesc Med. 2010;164(11):1045-1051

A LTHOUGH THE DEATH OF A

loved one is often highlystressful, most peopleeventually adjust to theirloss. Some people, how-

ever, have complicated grief, a syndromedistinct from usual grief and other recog-nized mental disorders.1-3 Symptoms ofcomplicated grief include intense yearn-ing for the deceased, a sense of disbeliefregarding the death, anger and bitter-ness, intrusive and preoccupying thoughtsof the deceased, avoidance of remindersof the loss, and difficulty moving on withlife. The persistence of these symptoms forat least 6 months has been associated withpoor mental and physical health out-comes and reduced quality of life.4-7

Most research on complicated grief hasbeen conducted in elderly individuals fol-

lowingspousal loss.1,4-6,8-16 Estimatedpreva-lence rates for complicated grief among be-reaved spouses range from 10% to 20%.6,8,9

Identifiedrisk factors includechildhoodad-versities (eg,abuse),10 childhoodseparation

anxiety,11 insecure attachment styles andmarital quality,12-14 lackofpreparedness forthe death,8,14 and demographic characteris-tics (eg, sex, race).5,15 Lackof social supporthasnotconsistentlybeenshownto increaseriskforcomplicatedgriefamongelderlywid-ows and widowers.16,17 The prevalence andriskfactors forcomplicatedgrief inotherbe-reavedgroupsare lesswell studiedpartlybe-cause other types of loss are less common.

Journal Club slides availableat www.archpediatrics.com

Author Affiliations are listed atthe end of this article.Group Information: The EuniceKennedy Shriver NationalInstitute of Child Health andHuman DevelopmentCollaborative Pediatric CriticalCare Research Network(CPCCRN) members are listedat the end of this article.

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 164 (NO. 11), NOV 2010 WWW.ARCHPEDIATRICS.COM1045

©2010 American Medical Association. All rights reserved.

Downloaded From: on 11/03/2018


40 studies varied rates from 0 to 75% ... ???some interventions might help: mindfulness, communication, ethics rounds

RESEARCH ARTICLE

The Prevalence of Compassion Fatigue andBurnout among Healthcare Professionals inIntensive Care Units: A Systematic ReviewMargo M. C. van Mol1*, Erwin J. O. Kompanje1, Dominique D. Benoit2, Jan Bakker1, MarjanD. Nijkamp3

1 Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, TheNetherlands, 2 Department of Intensive Care, Medical Unit Ghent University Hospital, Ghent, Belgium,3 Faculty of Psychology and Educational Sciences, Open University of the Netherlands, Heerlen, TheNetherlands

* [email protected]

Abstract

Background

Working in the stressful environment of the Intensive Care Unit (ICU) is an emotionally

charged challenge that might affect the emotional stability of medical staff. The quality of

care for ICU patients and their relatives might be threatened through long-term absenteeism

or a brain and skill drain if the healthcare professionals leave their jobs prematurely in order

to preserve their own health.

Purpose

The purpose of this review is to evaluate the literature related to emotional distress among

healthcare professionals in the ICU, with an emphasis on the prevalence of burnout and

compassion fatigue and the available preventive strategies.

Methods

A systematic literature review was conducted, using Embase, Medline OvidSP, Cinahl,

Web-of-science, PsychINFO, PubMed publisher, Cochrane and Google Scholar for articles

published between 1992 and June, 2014. Studies reporting the prevalence of burnout, com-

passion fatigue, secondary traumatic stress and vicarious trauma in ICU healthcare profes-

sionals were included, as well as related intervention studies.

Results

Forty of the 1623 identified publications, which included 14,770 respondents, met the selec-

tion criteria. Two studies reported the prevalence of compassion fatigue as 7.3% and 40%;

five studies described the prevalence of secondary traumatic stress ranging from 0% to

38.5%. The reported prevalence of burnout in the ICU varied from 0% to 70.1%. A wide

range of intervention strategies emerged from the recent literature search, such as different

PLOS ONE | DOI:10.1371/journal.pone.0136955 August 31, 2015 1 / 22

OPEN ACCESS

Citation: van Mol MMC, Kompanje EJO, Benoit DD,Bakker J, Nijkamp MD (2015) The Prevalence ofCompassion Fatigue and Burnout among HealthcareProfessionals in Intensive Care Units: A SystematicReview. PLoS ONE 10(8): e0136955. doi:10.1371/journal.pone.0136955

Editor: Soraya Seedat, University of Stellenbosch,SOUTH AFRICA

Received: September 27, 2014

Accepted: August 11, 2015

Published: August 31, 2015

Copyright: © 2015 van Mol et al. This is an openaccess article distributed under the terms of theCreative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in anymedium, provided the original author and source arecredited.

Data Availability Statement: All relevant data arewithin the paper and its Supporting Information files.

Funding: The authors have no support or funding toreport.

Competing Interests: The authors have declaredthat no competing interests exist.

RESEARCH ARTICLE

The Prevalence of Compassion Fatigue andBurnout among Healthcare Professionals inIntensive Care Units: A Systematic ReviewMargo M. C. van Mol1*, Erwin J. O. Kompanje1, Dominique D. Benoit2, Jan Bakker1, MarjanD. Nijkamp3

1 Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, TheNetherlands, 2 Department of Intensive Care, Medical Unit Ghent University Hospital, Ghent, Belgium,3 Faculty of Psychology and Educational Sciences, Open University of the Netherlands, Heerlen, TheNetherlands

* [email protected]

Abstract

Background

Working in the stressful environment of the Intensive Care Unit (ICU) is an emotionally

charged challenge that might affect the emotional stability of medical staff. The quality of

care for ICU patients and their relatives might be threatened through long-term absenteeism

or a brain and skill drain if the healthcare professionals leave their jobs prematurely in order

to preserve their own health.

Purpose

The purpose of this review is to evaluate the literature related to emotional distress among

healthcare professionals in the ICU, with an emphasis on the prevalence of burnout and

compassion fatigue and the available preventive strategies.

Methods

A systematic literature review was conducted, using Embase, Medline OvidSP, Cinahl,

Web-of-science, PsychINFO, PubMed publisher, Cochrane and Google Scholar for articles

published between 1992 and June, 2014. Studies reporting the prevalence of burnout, com-

passion fatigue, secondary traumatic stress and vicarious trauma in ICU healthcare profes-

sionals were included, as well as related intervention studies.

Results

Forty of the 1623 identified publications, which included 14,770 respondents, met the selec-

tion criteria. Two studies reported the prevalence of compassion fatigue as 7.3% and 40%;

five studies described the prevalence of secondary traumatic stress ranging from 0% to

38.5%. The reported prevalence of burnout in the ICU varied from 0% to 70.1%. A wide

range of intervention strategies emerged from the recent literature search, such as different


OPEN ACCESS

Citation: van Mol MMC, Kompanje EJO, Benoit DD,Bakker J, Nijkamp MD (2015) The Prevalence ofCompassion Fatigue and Burnout among HealthcareProfessionals in Intensive Care Units: A SystematicReview. PLoS ONE 10(8): e0136955. doi:10.1371/journal.pone.0136955

Editor: Soraya Seedat, University of Stellenbosch,SOUTH AFRICA

Received: September 27, 2014

Accepted: August 11, 2015

Published: August 31, 2015

Copyright: © 2015 van Mol et al. This is an openaccess article distributed under the terms of theCreative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in anymedium, provided the original author and source arecredited.

Data Availability Statement: All relevant data arewithin the paper and its Supporting Information files.

Funding: The authors have no support or funding toreport.

Competing Interests: The authors have declaredthat no competing interests exist.

the operating theatre (n = 88), 17.2% in the surgical department (n = 134), and 12.4% in themedical department (n = 109) [66]. No difference for the Neonatology Intensive Care Unit orPediatric Intensive Care Unit, with the prevalence ranging from 1.2% [20] to 41% [47], wasfound compared to the adult ICU, with the prevalence ranging from 16% [77] to 46.5% [46],measured with the MBI. Correspondingly, no clustering of prevalence rates was identified forspecific hospital settings (i.e., an academic or regional hospital), professional role (i.e., doctorsor nurses), or number of respondents in the study group.

A summary of the diverse measurement instruments, cut-off scores and reported preva-lence, are shown in Table 5.

The included studies reported a broad range of variables related to emotional distress, seeTable 6. Work environment [22,46,68,74], professional role [61,67] and conflicts [46,64] weresignificantly and positively related to the measured phenomenon. However, some studiesstated opposite results. Most confusing variable was the female sex, with an increasing [46,66]versus a decreasing [61] effect, and no significantly measured influence [42,50,52,64] on emo-tional distress.

Preventive StrategiesA wide range of intervention strategies to reduce emotional distress among ICU professionalsemerge from the recent literature, see Table 7. Ten studies measured the effect of an interven-tion, such as different intensivist work schedules [40,48], educational programs on emotionaldistress [45,58], improving elements of family-centered care and communication skills[56,65,71], strategies regarding personality and coping [62,63], and relaxation exercises [59,75]such as yoga and mindfulness. In addition, seven of the included studies suggested preventivestrategies, varying from improving the work environment [49,55,68], focussing more on socialsupport and individual coping strategies [54], changing team composition to include a greaternumber of women [61], developing teambuilding and periodic job rotation [42], and a mix ofall these elements [67].

According to Quenot et al. [65], the implementation of a set of active, intensive communica-tion strategies regarding end-of-life care in the ICU has been associated with significantlylower rates of BO after the intervention. These strategies comprised elements in the organiza-tion, (i.e., the introduction of unrestricted visiting hours and the availability of a staff psycholo-gist for consultation on demand), communication, (i.e., daily meetings of the caregiving teamwith the patient and/or their family and the discussion of palliative care options), ethics, (i.e., aspecial section in every patient´s medical record or ethical rounds), and stress debriefings andconflict prevention. Reductions of almost 50% and 60% were reported in the relative risk of BOand depression, respectively, after some of these interventions. Another promising preventivestrategy is mindfulness training. West et al. [80] measured a positive effect of 19 biweekly

Table 4. Amount of articles on the prevalence of emotional distress and prevalence range.

Mentioned in study (n) Prevalence range (%)

Burnout 28 (93.3%) 0.0–70.1

Emotional exhaustion 7.6–52.0

Depersonalization 3.3–41.8

Personal accomplishment 6.0–75.9

Compassion fatigue 5 (16.7%) 7.3–40.0

Secondary- and post-traumatic stress 6 (20.0%) 0.0–38.5

Vicarious trauma or stress 1 (3.3%)

doi:10.1371/journal.pone.0136955.t004

The Prevalence of Compassion Fatigue and Burnout


the operating theatre (n = 88), 17.2% in the surgical department (n = 134), and 12.4% in themedical department (n = 109) [66]. No difference for the Neonatology Intensive Care Unit orPediatric Intensive Care Unit, with the prevalence ranging from 1.2% [20] to 41% [47], wasfound compared to the adult ICU, with the prevalence ranging from 16% [77] to 46.5% [46],measured with the MBI. Correspondingly, no clustering of prevalence rates was identified forspecific hospital settings (i.e., an academic or regional hospital), professional role (i.e., doctorsor nurses), or number of respondents in the study group.

A summary of the diverse measurement instruments, cut-off scores and reported preva-lence, are shown in Table 5.

The included studies reported a broad range of variables related to emotional distress, seeTable 6. Work environment [22,46,68,74], professional role [61,67] and conflicts [46,64] weresignificantly and positively related to the measured phenomenon. However, some studiesstated opposite results. Most confusing variable was the female sex, with an increasing [46,66]versus a decreasing [61] effect, and no significantly measured influence [42,50,52,64] on emo-tional distress.

Preventive StrategiesA wide range of intervention strategies to reduce emotional distress among ICU professionalsemerge from the recent literature, see Table 7. Ten studies measured the effect of an interven-tion, such as different intensivist work schedules [40,48], educational programs on emotionaldistress [45,58], improving elements of family-centered care and communication skills[56,65,71], strategies regarding personality and coping [62,63], and relaxation exercises [59,75]such as yoga and mindfulness. In addition, seven of the included studies suggested preventivestrategies, varying from improving the work environment [49,55,68], focussing more on socialsupport and individual coping strategies [54], changing team composition to include a greaternumber of women [61], developing teambuilding and periodic job rotation [42], and a mix ofall these elements [67].

According to Quenot et al. [65], the implementation of a set of active, intensive communica-tion strategies regarding end-of-life care in the ICU has been associated with significantlylower rates of BO after the intervention. These strategies comprised elements in the organiza-tion, (i.e., the introduction of unrestricted visiting hours and the availability of a staff psycholo-gist for consultation on demand), communication, (i.e., daily meetings of the caregiving teamwith the patient and/or their family and the discussion of palliative care options), ethics, (i.e., aspecial section in every patient´s medical record or ethical rounds), and stress debriefings andconflict prevention. Reductions of almost 50% and 60% were reported in the relative risk of BOand depression, respectively, after some of these interventions. Another promising preventivestrategy is mindfulness training. West et al. [80] measured a positive effect of 19 biweekly

Table 4. Amount of articles on the prevalence of emotional distress and prevalence range.

Mentioned in study (n) Prevalence range (%)

Burnout 28 (93.3%) 0.0–70.1

Emotional exhaustion 7.6–52.0

Depersonalization 3.3–41.8

Personal accomplishment 6.0–75.9

Compassion fatigue 5 (16.7%) 7.3–40.0

Secondary- and post-traumatic stress 6 (20.0%) 0.0–38.5

Vicarious trauma or stress 1 (3.3%)

doi:10.1371/journal.pone.0136955.t004



PrevalenceStudies on the prevalence of CF and S/PTS in the ICU were less frequent than studies of BO, asshown in Table 4, and only one study mentioned VT [22]. The Professional Quality of Care(ProQOL) questionnaire, which was used in some of the reviewed studies, was developed tomeasure both CF and BO [78]. Additionally, this questionnaire distinguishes also the positiveeffects of caring, referred to as compassion satisfaction. Over time, this tool has been validatedin various healthcare work environments and has proven to be reliable and feasible for medicalstaff [27,79]. According to the ProQOL-revisited V, two different studies showed 7.3% [20]and 40% [22] of the respondents who scored high on CF compared with 1.2% and 23%, respec-tively, who had severe BO. Two other studies, which were using the ProQOL, measured a 0%

Fig 1. Flowchart review process. An adapted PRISMA flowchart of the total review process on the prevalence of compassion fatigue and burnout amonghealthcare professionals in the intensive care unit.

doi:10.1371/journal.pone.0136955.g001




RCT of intervention vs grief

476

or spouses/partners (n = 74, 35.6%). The CAESAR score indicated a good family experience of dying and death with a median score of 66 (66 [50–76] in the intervention group and 66 [52–78] in the control group).

InterventionsAll intervention-group relatives were sent a condolence letter 2 weeks after the patient’s death. All the letters complied with study guidelines and all included personal phrases and thoughts from physicians and nurses.

Feedback was received from 55 (44.7%) intervention-group relatives and 8 (6.7%) controls (P < 0.0001) and was consistently positive regarding quality of care. Of the 55 intervention-group relatives who gave feedback, 50 did so to thank the clinician for the condolence letter. No rel-atives complained about the condolence letter.

ICU specialists reported that writing a condolence let-ter was neither difficult nor time consuming and that, although it did not particularly help them, it could help family members (supplemental Table 1).

Primary outcomeAfter 1 month, the HADS score was 16 [10–22] in the intervention group and 14 [8–21.5] in the control group (P = 0.36) (Table 2; Fig. 2). The mean difference in HADS score was estimated at 0.77 (95% CI −1.7 to +3.3). Although scores were higher in the interven-tion group, there were no significant differences in the HADS-depression subscale (8 [4–12] vs. 6 [2–12],

mean difference, 1.1, 95% CI −0.5 to +2.6; P = 0.097) and prevalence of depression symptoms (56.0 vs. 42.4%, RR = 0.76, 95% CI 0.57–1.00; P = 0.054). There were also no significant differences in the HADS-anxiety subscale (7 [4–11] vs 7 [4–12]; P = 0.92) and prevalence of anxiety symptoms (47.7 vs 45.5%; P = 0.97).

Secondary outcomesAfter 6 months, the HADS score was significantly worse in the intervention group (13 [7–19] vs. 10 [4–17.5], P = 0.04) (Table 2; Fig. 2). The HADS-depression sub-scale score (6 [2–10] vs. 3 [1–9], mean difference of 1.4, 95% CI −0.14 to +2.90; P = 0.026) and prevalence of depression symptoms (36.6 vs. 24.7%, P = 0.05) were also higher with the intervention. The intervention group had a higher prevalence of PTSD-related symptoms (52.4 vs. 37.1%, P = 0.03) but similar prevalence of complicated-grief symptoms (37.6 vs. 29.2%, P = 0.28).

Risk factorsTable 3 reports the results of multivariate models of each outcome measure, where only variables selected by uni-variable analyses were introduced jointly. On the basis of multivariable analysis, a high 6-month HADS score (≥ 13) was unexpectedly associated with the condolence letter (OR 2.17, 95% CI 1.02–4.76), as well as patient’s age (the lower, the higher the odds of increased HADS) and family education level (OR 2.50, 95% CI 1.08–5.88), the spouse or partner status of the relative (OR 7.08, 95%

365 pa�ents assessed for eligibility

242 pa�ents randomized

123 assigned to condolence le�er 119 assigned to standard of care

Analyzed at 1 month (HADS and CAESAR scales): n=107 (87%)

Analyzed at 1 month (HADS and CAESAR scales): n=101 (85%)

Analyzed at 6 months (HADS, IES-R and ICG): 97 (79%)

Analyzed at 6 months (HADS, IES-R and ICG): 91 (76%)

Lost to follow-up (n=16)7 refused, 9 did not respond




• Not mee�ng inclusion criteria (n=81); • Declined to par�cipate (n=23); • Other reasons (n=19)

Fig. 1 Patient flow diagram

Intensive Care Med (2017) 43:473–484DOI 10.1007/s00134-016-4669-9

SEVEN-DAY PROFILE PUBLICATION

Effect of a condolence letter on grief symptoms among relatives of patients who died in the ICU: a randomized clinical trialNancy Kentish‑Barnes1, Sylvie Chevret2, Benoît Champigneulle3, Marina Thirion4, Virginie Souppart1, Marion Gilbert5, Olivier Lesieur6, Anne Renault7, Maïté Garrouste‑Orgeas8, Laurent Argaud9, Marion Venot10, Alexandre Demoule11, Olivier Guisset12, Isabelle Vinatier13, Gilles Troché14, Julien Massot15, Samir Jaber16, Caroline Bornstain17, Véronique Gaday18, René Robert19, Jean‑Philippe Rigaud20, Raphaël Cinotti21, Mélanie Adda22, François Thomas23, Laure Calvet24, Marion Galon1, Zoé Cohen‑Solal1, Alain Cariou25, Elie Azoulay1,26* and Famirea Study Group

© 2017 Springer‑Verlag Berlin Heidelberg and ESICM

Abstract

Purpose: Family members of patients who die in the intensive care unit (ICU) may experience symptoms of stress, anxiety, depression, posttraumatic stress disorder (PTSD), and/or prolonged grief. We evaluated whether grief symptoms were allevi‑ated if the physician and the nurse in charge at the time of death sent the closest relative a handwritten condolence letter.

Methods: Multicenter randomized trial conducted among 242 relatives of patients who died at 22 ICUs in France between December 2014 and October 2015. Relatives were randomly assigned to receiving (n = 123) or not receiv‑ing (n = 119) a condolence letter. The primary endpoint was the Hospital Anxiety and Depression Score (HADS) at 1 month. Secondary endpoints included HADS, complicated grief (ICG), and PTSD‑related symptoms (IES‑R) at 6 months. Observers were blinded to group allocation.

Results: At 1 month, 208 (85.9%) relatives completed the HADS; median score was 16 [IQR, 10–22] with and 14 [8–21.5] without the letter (P = 0.36). Although scores were higher in the intervention group, there were no significant differences regarding the HADS‑depression subscale (8 [4–12] vs. 6 [2–12], mean difference 1.1 [−0.5 to 2.6]; P = 0.09) and prevalence of depression symptoms (56.0 vs. 42.4%, RR 0.76 [0.57–1.00]; P = 0.05). At 6 months, 190 (78.5%) rela‑tives were interviewed. The intervention significantly increased the HADS (13 [7–19] vs. 10 [4–17.5], P = 0.04), HADS‑depression subscale (6 [2–10] vs. 3 [1–9], P = 0.02), prevalence of depression symptoms (36.6 vs. 24.7%, P = 0.05) and PTSD‑related symptoms (52.4 vs. 37.1%, P = 0.03).

Conclusions: In relatives of patients who died in the ICU, a condolence letter failed to alleviate grief symptoms and may have worsened depression and PTSD‑related symptoms.

Trial registration Clinicaltrials.gov Identifier: NCT02325297.

Keywords: Letter of condolence, Bereaved relatives, Grief symptoms

*Correspondence: [email protected] 26 Medical Intensive Care Unit, Hôpital Saint‑Louis, ECSTRA Team, and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University , 1 rue Claude Vellefaux, 75010 Paris, FranceFull author information is available at the end of the article

This study was performed on behalf of the Famirea Study Group.

All contributors are listed in the Electronic supplementary material 1.


242 relatives of patients who died at 22 ICUs in France@One month: 208 (85.9%) relatives no difference in Hospital Anxiety & Depression Score (p= 0.36)

@Six months:190 (78.5%) relatives. With letter.... worse HADS (13 vs. 10, p = 0.04). more depression symptoms (37 vs. 25%, p=0.05) more PTSD-related symptoms (52 vs. 37%, p=0.03)

RCT condolence letter : don’t


“....workplace anxiety will debilitate and facilitate job performance.” Cheng et. al. 2018.

“Somewhere between checked out and freaked out lies an anxiety sweet spot...” Wall Street Journal.

stress & disconnection


this is a heading

Introduction

It becomes more and more challenging for hospital manag-ers worldwide to retain clinicians in intensive care units (ICU) [1–5]. Currently, about 18–23% of ICU clinicians express an intention to leave their job in the United States and Europe [6, 7]. Besides irregular working hours and night/weekend shifts in an often chaotic and noisy environment, clinicians are increasingly confronted with morally distressing situa-tions often related to decision-making at end-of-life (EOL) [7–13]. The combination of technical innovation, which often prevents patient’s natural death, and the increasing number of potentially inappropriate admissions [7, 8, 14] render EOL decisions stressful, with postponed decision-making or even decision-paralysis as a consequence [7, 8, 14]. Whereas acute moral distress related to decision-paralysis may induce overt conflicts in the team [10, 15], more chronic forms of unex-pressed moral distress such as frustration, guilt, maladap-tive behavior, can ultimately cause job turnover [14–21]. As one of the strongest and most important predictors of actual

turnover in health care, besides job satisfaction, has been found to be turnover intention [1–6]. Past efforts to reduce burnout and job leave have mainly focused on empowering individuals’ resilience skills [5, 7, 9]. However, timely sharing knowledge, experience and values between different profes-sions within an open climate may further help in reducing moral distress and subsequently intention to leave [7–15, 20]. To our knowledge, the relationship between the intent to leave and the quality of inter-professional collaboration with regards to ethical decision-making in the ICU has never been assessed.

The main objective of this study, as shown in Fig. 1, was to assess the relationship between the quality of the ethical climate in the ICU and intent to leave after tak-ing country, ICU, and clinician factors into account. We

Conclusion: This is the first large multicenter study showing an independent association between clinicians’ intent to leave and the quality of the ethical climate in the ICU. Interventions to reduce intent to leave may be most effective when they focus on improving mutual respect, interdisciplinary reflection and active decision‑making at EOL.

Keywords: Intent to leave, Ethical climate, Interdisciplinary reflection, Decision‑making, Respect

Take‑home message

Interventions aiming to reduce or prevent intent to leave among the ICU workforce should focus on improving their ethical climate.

Fig. 1 Theoretical framework. ICU mortality (2013) as a surrogate marker for cumulative confrontation with end‑of‑life

Intensive Care Medhttps://doi.org/10.1007/s00134-019-05829-1

ORIGINAL

Ethical climate and intention to leave among critical care clinicians: an observational study in 68 intensive care units across Europe and the United StatesBo Van den Bulcke1* , Victoria Metaxa2, Anna K. Reyners3, Katerina Rusinova4, Hanne I. Jensen5, J. Malmgren6,7, Michael Darmon8, Daniel Talmor9, Anne‑Pascale Meert10, Laura Cancelliere11, László Zubek12, Paulo Maia13, Andrej Michalsen14, Erwin J. O. Kompanje15, Peter Vlerick16, Jolien Roels17, Stijn Vansteelandt17,18, Johan Decruyenaere1, Elie Azoulay8, Stijn Vanheule19, Ruth Piers20 and Dominique Benoit1 on behalf of the DISPROPRICUS study group of the Ethics Section of the ESICM

© 2019 The Author(s)

Abstract

Purpose: Apart from organizational issues, quality of inter‑professional collaboration during ethical decision‑making may affect the intention to leave one’s job. To determine whether ethical climate is associated with the intention to leave after adjustment for country, ICU and clinicians characteristics.

Methods: Perceptions of the ethical climate among clinicians working in 68 adult ICUs in 12 European countries and the US were measured using a self‑assessment questionnaire, together with job characteristics and intent to leave as a sub‑analysis of the Dispropricus study. The validated ethical decision‑making climate questionnaire included seven factors: not avoiding decision‑making at end‑of‑life (EOL), mutual respect within the interdisciplinary team, open interdisciplinary reflection, ethical awareness, self‑reflective physician leadership, active decision‑making at end‑of‑life by physicians, and involvement of nurses in EOL. Hierarchical mixed effect models were used to assess associations between these factors, and the intent to leave in clinicians within ICUs, within the different countries.

Results: Of 3610 nurses and 1137 physicians providing ICU bedside care, 63.1% and 62.9% participated, respectively. Of 2992 participating clinicians, 782 (26.1%) had intent to leave, of which 27% nurses, 24% junior and 22.7% senior physicians. After adjustment for country, ICU and clinicians characteristics, mutual respect OR 0.77 (95% CI 0.66‑ 0.90), open interdisciplinary reflection (OR 0.73 [95% CI 0.62–0.86]) and not avoiding EOL decisions (OR 0.87 [95% CI 0.77–0.98]) were all associated with a lower intent to leave.

*Correspondence: [email protected] 1 Department of Intensive Care Medicine, Ghent University Hospital, De Pintelaan 185, Ghent, BelgiumFull author information is available at the end of the article

Members of the "DISPROPRICUS study group of the Ethics Section of the ESICM" are listed in the acknowledgement section.

3610 nurses1137 physicians (RR 63%)12-EU nations + US26% with intent to leave

Intent to leave less likely if.. mutual respect (OR 0.77) open interdisciplinary reflection (OR 0.73) not avoiding EOL decisions (OR 0.87)


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Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.Unauthorized reproduction of this article is prohibited

Pediatric Critical Care Medicine www.pccmjournal.org S79

Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Objectives: To describe the consequences of workplace stressors on healthcare clinicians in PICU, and strategies for personal well-being, and professional effectiveness in providing high-quality end-of-life care.Data Sources: Literature review, clinical experience, and expert opinion.Study Selection: A sampling of foundational and current evidence was accessed.Data Synthesis: Narrative review and experiential reflection.Conclusions: The well-being of healthcare clinicians in the PICU influences the day-to-day quality and effectiveness of patient care, team functioning, and the retention of skilled individuals in the PICU workforce. End-of-life care, including decision making, can be com-plicated. Both are major stressors for PICU staff that can lead to adverse personal and professional consequences. Overresponsive-ness to routine stressors may be seen in those with moral distress,

and underresponsiveness may be seen in those with compassion fatigue or burnout. Ideally, all healthcare professionals in PICU can rise to the day-to-day workplace challenges—responding in an adap-tive, effective manner. Strategies to proactively increase resilience and well-being include self-awareness, self-care, situational aware-ness, and education to increase confidence and skills for providing end-of-life care. Reactive strategies include case conferences, pre-briefings in ongoing preidentified situations, debriefings, and other postevent meetings. Nurturing a culture of practice that acknowl-edges the emotional impacts of pediatric critical care work and cel-ebrates the shared experiences of families and clinicians to build resilient, effective, and professionally fulfilled healthcare profession-als thus enabling the provision of high-quality end-of-life care for chil-dren and their families. (Pediatr Crit Care Med 2018; 19:S79–S85)Key Words: burnout; compassionate fatigue; end of life; moral distress; pediatric critical care; resilience

PICU clinicians are the human instruments through which care in the PICU is delivered. Clinician well-being influences the day-to-day quality and effective-

ness of patient care, team functioning, and the retention of skilled individuals in the PICU (1–3). Routine PICU prac-tice exposes healthcare professionals to complex clinical dilemmas and challenging outcomes that can cause acute distress and, in some cases, can insidiously undermine personal well-being and effectiveness as clinicians (4, 5). In this article, we focus on the healthcare professional in PICU—describing consequences of providing care to the children who unfortunately die in PICU and their families. We describe practical approaches that may help clinicians better navigate the stresses of providing high-quality end-of-life (EOL) care.

DEFINING THE PROBLEM: STRESSORS IN THE PICUStressors are common in PICU work. Death has become an increasingly less frequent outcome in PICU, and expecta-tions of survival are higher (6). The majority of deaths follow

Care for Dying Children and Their Families in the PICU: Promoting Clinician Education, Support, and Resilience

Karen Dryden-Palmer, MSN, RN1,2; Daniel Garros, MD3,4; Elaine C. Meyer, PhD, RN5;

Catherine Farrell, MD, FRCPC6; Christopher S. Parshuram, MBChB, DPhil1,2

Pediatric Critical Care Medicine

Pediatr Crit Care Med

1529-7535

10.1097/PCC.0000000000001594

19

8

S79

S85

2018

DOI: 10.1097/PCC.0000000000001594

Gunasundari

XXX

xxx

August

2018

Dryden-Palmer et al

1Critical Care Program, The Hospital for Sick Children, Toronto, ON, Canada.2Center for Safety Research, Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.

3Stollery Children’s Hospital, Edmonton, AB, Canada.4Department of Pediatric Critical Care, John Dossetor Health Ethics Centre, University of Alberta, Edmonton, AB, Canada.

5Department of Psychiatry, Boston Children’s Hospital and Center for Bio-ethics, Harvard Medical School, Boston, MA.

6Division of Pediatric Intensive Care, CHU Sainte-Justine, Montréal, QC, Canada.

Dr. Meyer disclosed that she is an Associate Editor for Simulation in Healthcare. Dr. Farrell received funding from Centre hospitalier universi-taire Sainte-Justine and Canadian Paediatric Society. Dr. Parshuram dis-closed other support from Robin DeVerteuil Foundation (as specified in the introduction article) and disclosed he is a named inventor of the patent of the Bedside Paediatric Early Warning System (the patent owner is the Hospital for Sick Children). He has received funding from holding shares in Bedside Clinical Systems, a clinical decision support company in part owned by the Hospital for Sick Children. The remaining authors have dis-closed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: [email protected]


Dryden-Palmer et al

S82 www.pccmjournal.org August 2018 • Volume 19 • Number 8 (Suppl.)

participants than in nonparticipants (36). Tools for self-aware-ness and self-care may be available through employers and professional organizations such as the “Mindfulness Project”

at the Hospital for Sick Children (Toronto, ON, Canada) where structured support is offered to learn and practice mindfulness techniques (27).

TABLE 1. Interventions for Proactive and Responsive Management of Clinician Distress

Activity Goal(s) Examples

Proactive interventions: awareness/self care

Capacity building Build emotional regulatory skills Mindfulness education and practice support (27)

Focus attention Reflective practice exercises

Work-life balance Physical and emotional wellness Scheduling practices/human resource policy

Team building activities

Personal health Physical/emotional wellness Employee assistance programs

Wellness education/programs (pet therapy programs)

Recognition Facilitate engagement Employee recognition programs

Team engagement initiatives

Proactive interventions: preparedness and situational awareness

Structured education Enhance moral reasoning Formal education programs (Mindful Ethical Practice and Resilience Academy) (28)

Knowledge building Facilitated interest groups/journal clubs

Simulation Build therapeutic and relational skills

EOL care simulation

Confidence building Disclosure workshops (Program to Enhance Relational and Communication Skills) (29)

Event simulation

Facilitated experiential learning Enhance moral sensitivity Case review (Schwartz rounds) (30)

Exercise moral reasoning Situationally grounded rounds (Care and Reflective Ethical Dialogue) (31)

Proactive interventions: relational

Point of care mindfulness Facilitate focus and engagement in the moment of care

The “Pause” (32)

Engagement with EOL proactive practices (three wishes project) (33)

Planned peer support networking Context-specific structured peer connections

Facilitated dialogue—“town hall” (group level)

Check out process (individual level)

Responsive interventions: situation focused

Case review Enhance moral reasoning Prebrief

Knowledge building Case-specific ethics round

Group awareness

Defusing debriefing Foster shared understanding Postevent debriefings

Enhance communication Critical incident stress debriefing (34)

Informal interpersonal support Event-specific peer support Point of care peer-to-peer interactions

Transparent and open communication culture

Expert consultation Knowledge building Bioethics consultation

Perspective making Employee assistance programs

EOL = end of life.

pro-active / responsive action


Neonatal & Paediatric ICU54 Canadian neonatal & PICU ICUs in31 hospitals 49(91%) ICUs & 2852 responses

n= 303

n= 792

n= 885

n= 621

n= 234

Previous Study

Current Study

Yes

No

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

0 50 100 150MDS−R Score

Moral Distress Self ReportI would say work causes me significant moral distress ...

Figure 1.

Moral Distress Scale-Revised scores

Median and IQR

0

100

200

300

0−10

10−2

020

−30

30−4

040

−50

50−6

060

−70

70−8

080

−90

90−1

0010

0−11

011

0−12

012

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013

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014

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015

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016

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017

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018

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019

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023

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024

0−25

025

0+

MDS−R score

Num

ber o

f Res

pond

ents


variance explained for MDS 1% region, 5% hospital 1% ICU (NICU-PICU same) 92% individual Uncertainty 96% individual Burnout 95% individual

> milieu - limited impact “its all (well 90%+) about individuals”

the milieu seems less important

1.2% of residuals > 110

Subject; SD=39.1 (92.4%)

ICU; SD=4.9 (1.4%)

Hospital; SD=9.1 (5.0%)

Region; SD=4.4 (1.2%)

−100 −50 0 50 100

0

25

50

75

100

0

25

50

75

100

0

25

50

75

100

0

25

50

75

100

Random effect or residual (MDS points)

Perc

entil

e

Variability attributable toregion, hospital, ICU and subject


distress disconnectiongrowth opportunity recovery -letting golearning moment objectivity humanism professionalism

compartmentalization

good stress & disconnection

work performance personal wellbeingemployee turnover


this is a headingsans heading 2

burnout moral distress

‘job stress’job satisfactionintent to leave staff turnover

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/pccmjournalby

BhDMf5ePH

Kav1zEoum1tQ

fN4a+kJLhEZgbsIH

o4XMi0hC

ywCX1AW

nYQp/IlQ

rHD3O

htCM0V8Q

hPQv1O

7eNJfYtQ

/EazM+r63m

3Y4Q/MwJdE=

on11/01/2018

Downloadedfromhttps://journals.lww.com/pccmjournalbyBhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3OhtCM0V8QhPQv1O7eNJfYtQ/EazM+r63m3Y4Q/MwJdE=on11/01/2018



Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

Objectives: To describe the consequences of workplace stressors on healthcare clinicians in PICU, and strategies for personal well-being, and professional effectiveness in providing high-quality end-of-life care.Data Sources: Literature review, clinical experience, and expert opinion.Study Selection: A sampling of foundational and current evidence was accessed.Data Synthesis: Narrative review and experiential reflection.Conclusions: The well-being of healthcare clinicians in the PICU influences the day-to-day quality and effectiveness of patient care, team functioning, and the retention of skilled individuals in the PICU workforce. End-of-life care, including decision making, can be com-plicated. Both are major stressors for PICU staff that can lead to adverse personal and professional consequences. Overresponsive-ness to routine stressors may be seen in those with moral distress,

and underresponsiveness may be seen in those with compassion fatigue or burnout. Ideally, all healthcare professionals in PICU can rise to the day-to-day workplace challenges—responding in an adap-tive, effective manner. Strategies to proactively increase resilience and well-being include self-awareness, self-care, situational aware-ness, and education to increase confidence and skills for providing end-of-life care. Reactive strategies include case conferences, pre-briefings in ongoing preidentified situations, debriefings, and other postevent meetings. Nurturing a culture of practice that acknowl-edges the emotional impacts of pediatric critical care work and cel-ebrates the shared experiences of families and clinicians to build resilient, effective, and professionally fulfilled healthcare profession-als thus enabling the provision of high-quality end-of-life care for chil-dren and their families. (Pediatr Crit Care Med 2018; 19:S79–S85)Key Words: burnout; compassionate fatigue; end of life; moral distress; pediatric critical care; resilience

PICU clinicians are the human instruments through which care in the PICU is delivered. Clinician well-being influences the day-to-day quality and effective-

ness of patient care, team functioning, and the retention of skilled individuals in the PICU (1–3). Routine PICU prac-tice exposes healthcare professionals to complex clinical dilemmas and challenging outcomes that can cause acute distress and, in some cases, can insidiously undermine personal well-being and effectiveness as clinicians (4, 5). In this article, we focus on the healthcare professional in PICU—describing consequences of providing care to the children who unfortunately die in PICU and their families. We describe practical approaches that may help clinicians better navigate the stresses of providing high-quality end-of-life (EOL) care.

DEFINING THE PROBLEM: STRESSORS IN THE PICUStressors are common in PICU work. Death has become an increasingly less frequent outcome in PICU, and expecta-tions of survival are higher (6). The majority of deaths follow

Care for Dying Children and Their Families in the PICU: Promoting Clinician Education, Support, and Resilience

Karen Dryden-Palmer, MSN, RN1,2; Daniel Garros, MD3,4; Elaine C. Meyer, PhD, RN5;

Catherine Farrell, MD, FRCPC6; Christopher S. Parshuram, MBChB, DPhil1,2

Pediatric Critical Care Medicine

Pediatr Crit Care Med

1529-7535

10.1097/PCC.0000000000001594

19

8

S79

S85

2018

DOI: 10.1097/PCC.0000000000001594

Gunasundari

XXX

xxx

August

2018

Dryden-Palmer et al

1Critical Care Program, The Hospital for Sick Children, Toronto, ON, Canada.2Center for Safety Research, Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.

3Stollery Children’s Hospital, Edmonton, AB, Canada.4Department of Pediatric Critical Care, John Dossetor Health Ethics Centre, University of Alberta, Edmonton, AB, Canada.

5Department of Psychiatry, Boston Children’s Hospital and Center for Bio-ethics, Harvard Medical School, Boston, MA.

6Division of Pediatric Intensive Care, CHU Sainte-Justine, Montréal, QC, Canada.

Dr. Meyer disclosed that she is an Associate Editor for Simulation in Healthcare. Dr. Farrell received funding from Centre hospitalier universi-taire Sainte-Justine and Canadian Paediatric Society. Dr. Parshuram dis-closed other support from Robin DeVerteuil Foundation (as specified in the introduction article) and disclosed he is a named inventor of the patent of the Bedside Paediatric Early Warning System (the patent owner is the Hospital for Sick Children). He has received funding from holding shares in Bedside Clinical Systems, a clinical decision support company in part owned by the Hospital for Sick Children. The remaining authors have dis-closed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: [email protected]


Supplement


for compassion fatigue are limited. In a review of the available compassion fatigue and burnout literature, van Mol et al (5) found that 7.3% of PICU clinicians and 40% of ICU nurses scored high for compassion fatigue on the Professional Quality of Care questionnaire.

The mutable nature of PICU clinician stress opens up opportunity where interventions may facilitate adaptive clini-cian responses thus improving resilience and mitigating other adverse consequences of workplace stressors (1). In contrast to the negatively framed states of moral distress, burnout, and compassion fatigue, resilience may be viewed as enabling healthcare professionals to effectively respond to stressors while optimizing opportunities for personal growth. Resilience is the ability of a person to manifest adaptive coping strategies that are matched to the situation while minimizing stress or distress, or to create personal meaning when circumstances are painful, overwhelming, or unreasonable (23). Resilience exists on a continuum, and resilient individuals are more efficient at resisting work-related stressors that can lead to moral distress, burnout, and depression, thus enabling them to continue to provide high-quality patient care.

We believe that the stressors present in PICU can cre-ate either virtuous and productive or destructive spirals. Virtuous spirals can create individual and team level resilience

that may be enabled by well-selected proactive interven-tions. Destructive spirals may reduce professional effec-tiveness and personal well-being of clinicians and may be “managed” by responsive strategies (4). Resilience in healthcare has been viewed as a process rather than a trait and thus may be cultivated and attained. Cultivating resil-ience is the goal of interven-tions that promote clinician well-being such that stress responses are maintained in the adaptive zone (2, 24).

ACQUIRING AND MAINTAINING CLINICIAN WELL-BEINGInterventions to promote and maintain clinician compe-tence and well-being may be understood as proactive or responsive in nature (Table 1). Responsive interventions are deployed to mitigate adverse consequences after “events,” challenging situations, or

other crises have occurred, whereas proactive interventions are implemented beforehand and intended to increase resilience of the frontline staff for managing future stressors. Here, we focus on stressors related to EOL care. The healthcare community has long recognized the importance of educating practitioners about EOL care (25). The interventions we describe in the con-text of EOL care can also assist when facing other stress-pro-voking phenomena such as difficult disclosures or disrupted relationships and include the domains of self-awareness and care, preparatory and relational skills, empathic presence, and the team approach (26).

PROACTIVE WELL-BEING INTERVENTIONSProactive interventions address self-awareness, self-care, situ-ational awareness, and build competence and confidence in one’s skills to provide EOL care (4). Personal initiatives for sustaining clinician wellness include self-care (e.g., exer-cise, rest, nutrition), self-awareness (e.g., reflective practices, mindfulness, journaling), cultivating emotional wellness (pet therapy) and a spiritual life, valuing relationships, and seek-ing self-education and conscious recognition of the degree of uncertainty inherent in the job (35). Studies of mindfulness interventions have shown decreased depression and anxiety and demonstrated higher empathy measures in mindfulness

Figure 1. The figure describes day-to-day levels of stress in ICU clinicians. Individual level of stress may change overtime and fluctuate between zones reflecting changes in the work environment and in individual disposition. Each black line represents an individual clinician. Shown are examples of some of the possible alter-nate trajectories of provider experience of stress. Dynamic factors such as past stressors, the prevailing work culture, available resources, and resilience of the individual healthcare clinician will affect the day-to-day level of stress and the responses to stressors at different times. Three zones identify differing responses to workplace stressors (behavioral, psychologic, and emotional). Workplace stressors are routinely encountered in pediatric critical care and should elicit responses from clinicians. Ideally, these responses are adaptive and timely actions that resolve (or mitigate) the course of stress (green zone). Underactive responses to workplace stressors (orange zone) may signal disengagement, emotional exhaustion, or withdrawal and may reflect burnout or com-passion fatigue. Overactive responses (red zone) could point toward hypersensitivity, anxiety, and disequilibrium and may reflect moral distress and risks for job departure. Both the overactive and underactive zones reflect conditions of potentially detrimental levels of stress.


Figure 1.

Moral Distress Scale-Revised scores

Median and IQR

0

100

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300

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10−2

020

−30

30−4

040

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50−6

060

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ber o

f Res

pond

ents

optimal performanceoptimal performance zoneleast @ high & low stress‘inverted U’ an P&DP original thought...

:(not).

Copyright ©

2018 by the Society of C

ritical Care M

edicine and the World F

ederation of Pediatric Intensive and C

ritical Care S

ocieties.U

nauthorized reproduction of this article is prohibited

Supplem

ent

Pediatric C

ritical Care M

edicine w

ww

.pccm

journ

al.o

rg S

81

for compassion

fatigue are lim

ited. In a review

of the available

compassion

fatigue an

d burn

out literatu

re, van M

ol et al (5) fou

nd th

at 7.3% of P

ICU

clinician

s and 40%

of ICU

nu

rses scored h

igh for com

passion fatigu

e on th

e Profession

al Qu

ality of C

are question

naire.

Th

e mu

table natu

re of PIC

U clin

ician stress op

ens u

p opp

ortun

ity wh

ere interven

tions m

ay facilitate adaptive clin

i-cian

respon

ses thus im

proving resilien

ce and m

itigating oth

er adverse con

sequen

ces of workplace stressors (1). In

contrast

to the n

egatively framed states of m

oral distress, burn

out,

and

compassion

fatigue, resilien

ce may be view

ed as enablin

g h

ealthcare

professionals

to effectively

respon

d to

stressors w

hile op

timizin

g opportu

nities for p

ersonal grow

th. R

esilience

is the ability of a p

erson to m

anifest adap

tive coping strategies

that are m

atched to th

e situation

wh

ile min

imizin

g stress or d

istress, or to create person

al mean

ing w

hen

circum

stances are

pain

ful, overw

helm

ing, or u

nreason

able (23). Resilien

ce exists on

a contin

uu

m, an

d resilient in

dividuals are m

ore efficien

t at resistin

g work-related stressors th

at can lead to m

oral distress, bu

rnou

t, and depression

, thus en

abling th

em to con

tinu

e to provide h

igh-qu

ality patient care.

We believe th

at the stressors p

resent in

PIC

U can

cre-ate eith

er virtuou

s and

pro

du

ctive or destru

ctive spirals.

Virtu

ous sp

irals can create in

divid

ual an

d team

level resilience

that m

ay be enabled

by well-

selected

pro

active in

terven-

tions. D

estructive sp

irals may

redu

ce p

rofessional

effec-tiven

ess an

d

person

al w

ell-bein

g of clinician

s and

may

be “man

aged”

by resp

onsive

strategies (4).

Resilien

ce in

h

ealthcare h

as been view

ed as

a pro

cess rather th

an a trait

and

th

us

may

be cu

ltivated

and

attained

. Cu

ltivating resil-

ience is th

e goal of in

terven-

tions th

at prom

ote clin

ician

well-b

eing

such

th

at stress

respon

ses are main

tained

in

the ad

aptive zon

e (2, 24).

AC

QU

IRIN

G A

ND

M

AIN

TAIN

ING

C

LINIC

IAN

WE

LL-B

EIN

GIn

tervention

s to promote an

d m

aintain

clin

ician

comp

e-ten

ce and

well-bein

g may be

un

derstood as

proactive or

respon

sive in n

ature (Tab

le 1). R

espon

sive in

tervention

s are

deployed to

mitigate

adverse con

sequen

ces after

“events,”

challen

ging

situation

s, or

other crises h

ave occurred, w

hereas proactive in

tervention

s are im

plemen

ted beforehan

d and in

tended to in

crease resilience of

the fron

tline staff for m

anagin

g futu

re stressors. Here, w

e focus

on stressors related to E

OL

care. Th

e health

care comm

un

ity h

as long recogn

ized the im

portan

ce of educatin

g practitioners

about E

OL

care (25). Th

e interven

tions w

e describe in th

e con-

text of EO

L care can

also assist wh

en facin

g other stress-pro-

voking ph

enom

ena su

ch as diffi

cult disclosu

res or disrup

ted relation

ships an

d inclu

de the dom

ains of self-aw

areness an

d care, preparatory an

d relational skills, em

path

ic presence, an

d th

e team approach

(26).

PR

OA

CTIV

E W

ELL-B

EIN

G IN

TER

VE

NTIO

NS

Proactive in

tervention

s address self-aw

areness, self-care, situ

-ation

al aw

areness,

and

build

com

peten

ce an

d con

fiden

ce in

one’s skills to provide E

OL

care (4). Personal in

itiatives for su

stainin

g clinician

welln

ess inclu

de self-care (e.g., exer-cise, rest, n

utrition

), self-awaren

ess (e.g., reflective practices,

min

dfuln

ess, journ

aling), cu

ltivating em

otional w

ellness (p

et th

erapy) and a spiritu

al life, valuin

g relationsh

ips, and

seek-in

g self-education

and con

scious recogn

ition of th

e degree of u

ncertain

ty inh

erent in

the job (35). Stu

dies of min

dfuln

ess in

tervention

s have sh

own

decreased depression an

d an

xiety an

d demon

strated high

er empathy m

easures in

min

dfuln

ess

Fig

ure 1. The figure describes day-to-day levels of stress in IC

U clinicians. Individual level of stress m

ay change overtim

e and fluctuate between zones reflecting changes in the w

ork environment and in individual

disposition. Each black line represents an individual clinician. S

hown are exam

ples of some of the possible alter-

nate trajectories of provider experience of stress. Dynam

ic factors such as past stressors, the prevailing work

culture, available resources, and resilience of the individual healthcare clinician will affect the day-to-day level of

stress and the responses to stressors at different times. Three zones identify differing responses to w

orkplace stressors (behavioral, psychologic, and em

otional). Workplace stressors are routinely encountered in pediatric

critical care and should elicit responses from clinicians. Ideally, these responses are adaptive and tim

ely actions that resolve (or m

itigate) the course of stress (green zone). Underactive responses to w

orkplace stressors (orange zone) m

ay signal disengagement, em

otional exhaustion, or withdraw

al and may reflect burnout or com

-passion fatigue. O

veractive responses (red zone) could point toward hypersensitivity, anxiety, and disequilibrium

and m

ay reflect moral distress and risks for job departure. B

oth the overactive and underactive zones reflect conditions of potentially detrim

ental levels of stress.

perfo

rman

ce

Copyright ©

2018 by the Society of C

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edicine and the World F

ederation of Pediatric Intensive and C

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ocieties.

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Supplem

ent

Pediatric C

ritical Care M

edicine

ww

w.p

cc

mjo

urn

al.o

rg

S81

for compassion

fatigue are lim

ited. In a review

of the available

compassion

fatigue an

d burn

out literatu

re, van M

ol et al (5)

foun

d that 7.3%

of PIC

U clin

icians an

d 40% of IC

U n

urses

scored high

for compassion

fatigue on

the P

rofessional Q

uality

of Care qu

estionn

aire.

Th

e mu

table natu

re of PIC

U clin

ician stress op

ens u

p

opportu

nity w

here in

tervention

s may facilitate adap

tive clini-

cian resp

onses thu

s improvin

g resilience an

d mitigatin

g other

adverse consequ

ences of w

orkplace stressors (1). In con

trast

to the n

egatively framed states of m

oral distress, burn

out,

and com

passion fatigu

e, resilience m

ay be viewed as en

abling

health

care profession

als to

effectively resp

ond

to stressors

wh

ile optim

izing opp

ortun

ities for person

al growth

. Resilien

ce

is the ability of a p

erson to m

anifest adap

tive coping strategies

that are m

atched to th

e situation

wh

ile min

imizin

g stress or

distress, or to create person

al mean

ing w

hen

circum

stances are

painfu

l, overwh

elmin

g, or un

reasonable (23). R

esilience exists

on a con

tinu

um

, and resilien

t individu

als are more effi

cient at

resisting w

ork-related stressors that can

lead to moral distress,

burn

out, an

d depression, thu

s enablin

g them

to contin

ue to

provide high

-quality patien

t care.

We believe th

at the stressors p

resent in

PIC

U can

cre-

ate either virtu

ous an

d p

rod

uctive or d

estructive sp

irals.

Virtu

ous sp

irals can create in

divid

ual an

d team

level resilience

that m

ay be enabled

by well-

selected

pro

active in

terven-

tions. D

estructive sp

irals may

redu

ce p

rofessional

effec-

tiveness

and

p

ersonal

well-

being of clin

icians an

d m

ay

be “man

aged”

by resp

onsive

strategies (4).

Resilien

ce in

health

care has been

viewed

as

a pro

cess rather th

an a trait

and

th

us

may

be cu

ltivated

and

attained

. Cu

ltivating resil-

ience is th

e goal of in

terven-

tions th

at prom

ote clinician

well-bein

g su

ch

that

stress

respon

ses are main

tained

in

the ad

aptive zon

e (2, 24).

AC

QU

IRIN

G A

ND

MA

INTA

ININ

G

CLIN

ICIA

N W

ELL-

BE

ING

Interven

tions to prom

ote and

main

tain

clinician

com

pe-

tence an

d well-bein

g may be

un

derstood as

proactive or

respon

sive in n

ature (Tab

le 1).

Resp

onsive

interven

tions

are

deployed to

mitigate

adverse

consequ

ences

after “even

ts,”

challen

ging

situation

s,

or

other crises h

ave occurred, w

hereas proactive in

tervention

s are

implem

ented beforeh

and an

d inten

ded to increase resilien

ce of

the fron

tline staff for m

anagin

g futu

re stressors. Here, w

e focus

on stressors related to E

OL

care. Th

e health

care comm

un

ity

has lon

g recognized th

e imp

ortance of edu

cating practition

ers

about E

OL

care (25). Th

e interven

tions w

e describe in th

e con-

text of EO

L care can

also assist wh

en facin

g other stress-pro-

voking ph

enom

ena su

ch as diffi

cult disclosu

res or disrup

ted

relationsh

ips and in

clude th

e domain

s of self-awaren

ess and

care, preparatory and relation

al skills, empath

ic presence, an

d

the team

approach (26).

PR

OA

CTIV

E W

ELL-B

EIN

G IN

TER

VE

NTIO

NS

Proactive in

tervention

s address self-awaren

ess, self-care, situ-

ational

awaren

ess, an

d bu

ild com

peten

ce an

d con

fiden

ce

in on

e’s skills to provide EO

L care (4). Person

al initiatives

for sustain

ing clin

ician w

ellness in

clude self-care (e.g., exer-

cise, rest, nu

trition), self-aw

areness (e.g., refl

ective practices,

min

dfuln

ess, journ

aling), cu

ltivating em

otional w

ellness (p

et

therapy) an

d a spiritual life, valu

ing relation

ships, an

d seek-

ing self-edu

cation an

d consciou

s recognition

of the degree of

un

certainty in

heren

t in th

e job (35). Studies of m

indfu

lness

interven

tions h

ave show

n decreased depression

and an

xiety

and dem

onstrated h

igher em

pathy measu

res in m

indfu

lness

Fig

ure 1. The figure describes day-to-day levels of stress in IC

U clinicians. Individual level of stress m

ay

change overtime and fluctuate betw

een zones reflecting changes in the work environm

ent and in individual

disposition. Each black line represents an individual clinician. S

hown are exam

ples of some of the possible alter-

nate trajectories of provider experience of stress. Dynam

ic factors such as past stressors, the prevailing work

culture, available resources, and resilience of the individual healthcare clinician will affect the day-to-day level of

stress and the responses to stressors at different times. Three zones identify differing responses to w

orkplace

stressors (behavioral, psychologic, and emotional). W

orkplace stressors are routinely encountered in pediatric

critical care and should elicit responses from clinicians. Ideally, these responses are adaptive and tim

ely actions

that resolve (or mitigate) the course of stress (green zone). U

nderactive responses to workplace stressors

(orange zone) may signal disengagem

ent, emotional exhaustion, or w

ithdrawal and m

ay reflect burnout or com-

passion fatigue. Overactive responses (red zone) could point tow

ard hypersensitivity, anxiety, and disequilibrium

and may reflect m

oral distress and risks for job departure. Both the overactive and underactive zones reflect

conditions of potentially detrimental levels of stress.

stress level

gradual decrease

abrupt reduction


Yerkes-Dodson ‘law’ (1908)optimal zoneunder | overpsychol 101face-validity? data


modification vs task expertise high face validityindividual & team Kotaskis and Kavanagh

task difficulty


disconnection


fMRI blood oxygen level dependent responses

differential activiationsneedle vs. ‘Q-tip’ physicians different....less affective: ant. insula & ant. cingulate cortex

more emotion regulation / cognitive control:

medial & dorsolateral prefrontal cortices

.... vs ‘control’ humansits probably good that proceduralists are ‘disconnected’

disconnection Current Biology 17, 1708–1713, October 9, 2007 ª2007 Elsevier Ltd All rights reserved DOI 10.1016/j.cub.2007.09.020

ReportExpertise Modulatesthe Perception of Pain in Others

Yawei Cheng,1,2 Ching-Po Lin,2 Ho-Ling Liu,3

Yuan-Yu Hsu,4 Kun-Eng Lim,5 Daisy Hung,2

and Jean Decety5,6,*1Department of RehabilitationTaipei City HospitalTaipei 103Taiwan2Institute of NeuroscienceNational Yang-Ming UniversityTaipei 112Taiwan3Department of Medical Imaging and RadiologicalSciences

Chang-Gung UniversityTaoyuan 333Taiwan4Department of Medical ImagingBuddhist Tzu-Chi General HospitalTaipei 231Taiwan5Department of Psychology6Department of PsychiatryThe University of ChicagoChicago, Illinois 60637

Summary

Perceiving the pain of others activates a large part ofthe painmatrix in the observer [1]. Because this shared

neural representation can lead to empathy or personaldistress [2, 3], regulatory mechanismsmust operate in

people who inflict painful procedures in their practicewith patient populations in order to prevent their dis-

tress from impairing their ability to be of assistance.In this functional magnetic resonance imaging MRI

study, physicians who practice acupuncture werecompared to naive participants while observing ani-

mated visual stimuli depicting needles being insertedinto different body parts, including the mouth region,

hands, and feet. Results indicate that the anterior in-sula somatosensory cortex, periaqueducal gray, and

anterior cingulate cortex were significantly activatedin the control group, but not in the expert group, who

instead showed activation of the medial and superiorprefrontal cortices and the temporoparietal junction,

involved in emotion regulation and theory of mind.

Results

We investigated the difference in the neurohemody-namic response between two groups of participants(medical doctors with at least 2 years of practice in acu-puncture, experts; and age and educational matched in-dividuals, controls) who were scanned while watching

dynamic visual stimuli depicting body parts in both non-painful situations (being touched with a Q-tip) and (po-tentially painful) acupuncture (being pricked by needles)situations. We predicted that the pain matrix would bedifferentially activated in expert participants with expe-rience in administering acupuncture as compared tocontrol participants when watching acupuncture proce-dures. Indeed, although participants who have expertisein acupuncture procedures know that such situationscan be painful for their patients, they have learnedthroughout their training and practice to keep a de-tached perspective; without such a mechanism, per-forming their clinical practice could be overwhelmingor distressing. Therefore, we anticipated that the re-gions involved in the affective aspects of pain process-ing, namely the anterior insula and anterior cingulatecortex (ACC), would not show increased activation inthe expert group. Instead, regions associated with emo-tion regulation and cognitive control, such as the medialand dorsolateral prefrontal cortices, were predicted toshow selective activation in expert population. We fur-ther predicted an enhanced self-other distinction in theexpert group, represented neurally as additional activa-tion of the right temporoparietal junction, an area knownto play a crucial role in self-other distinction processesand theory of mind [2, 4].The analyses of the dispositional measures revealed

no difference between the two groups [main effect ofthe group, F(1, 13) = 1.273, p = 0.28] (Table 1). However,the two one-way analyses of variance (ANOVAs) on thevisual analog scale (VAS) ratings indicated significantdifferences between the two groups separately for painintensity [F(1, 26) = 18.887, p = 0.00019] and unpleasant-ness [F(1,26)=22.465,p=0.00007], such that control par-ticipants reported significantly higher pain intensity andunpleasantness ratings thandidexpert participants.Sim-ilar ratings from watching different body parts (mouth,hand, and foot) were also found [pain intensity: F(2, 39) =0.197, p = 0.912; unpleasantness: F(2, 39) = 0.67, p =0.893]. All participants correctly reported the number ofstops on the continuous performance task when watch-ing the visual stimuli in the scanning sessions.The observation of body parts in painful situations

(needle versus fixation) in the control participants re-sulted in the activation of a neural network similar tothat observed in previous studies of pain empathy, in-cluding regions involved in the sensory and affectiveprocessing of pain (see Table S1 in the SupplementalData available online). In contrast, the expert groupshowed no signal change in the insula and ACC (evenwhen results were examined at the most liberal thresh-old). Instead, in the expert group, robust activationwas detected in occipital, hippocampus, and precentralgyri, which indicates that participants had indeed at-tended to the stimuli. The observation of body parts innonpainful situations (Q-tip versus fixation) elicited sim-ilar brain activity without involving the pain matrix inboth the control and expert groups (see Table S2).*Correspondence: [email protected]

The differential activation of watching the painful (nee-dle) and nonpainful (Q-tip) situations within each groupconfirmed that the control participants but not the expertparticipants activated the pain matrix when watchingbody parts being pricked by a needle relative to beingtouched by a Q-tip (see Table S3). Specifically, a signifi-cant signal increase was detected in the anterior medialcingulate cortex (aMCC) (x 4, y 18, z 45) and bilateral

anterior insula (x 40, y 20, z 210; x 236, y 16, z 22), aswell as the periaqueducal gray (PAG). Direct comparisonbetween the controls and experts revealed that the ac-tivity in the ACC and bilateral insula was reliably greaterin the controls when watching the acupuncture proce-dures. In contrast, the activity in the parahippocampalgyrus, medial prefrontal cortex (mPFC) (x 4, y 62,z 6),superior frontal gyrus (x 14, y 42, z 50), and right tempo-roparietal junction (x 36, y254, z 40) was stronger in theexperts while performing the same task (see Table S4)(Figure 1). Besides, the left postcentral gyrus (x 260,y226, z 20) was activated in the controls, a finding con-sistent with the automaticmapping of seen pain onto the(contralateral) sensorimotor cortex [5, 6]; whereas theright postcentral gyrus (x 50, y 214, z 28) was activatedin the experts. For the Q-tip stimuli, however, no suchdouble dissociation was observed (see Table S5).So that the differential activity related to the effect of

expertise could be uncovered, an interaction analysiswas calculated for the two contrasts (controls watchingneedles versus Q-tips and experts watching needlesversus Q-tips). This interaction demonstrates that thecontrols had stronger bilateral activation in the insula(x 40, y 22, z 214; x 238, y 16, z 28) and ACC (x 0, y24, z 30) than did the experts. The reverse comparison,however, shows that the experts had stronger activationin the superior frontal gyrus (x 14, y 34, z 48; x212, y 24,z 52) andmPFC (x214, y 58, z 8; x 10, y 60, z 14) than didthe controls (see Table S6). This suggests that the signif-icance of the interaction was mainly driven from the

Table 1. Dispositional Measures of Empathy and Ratings of Pain

Intensity and Unpleasantness in the Expert and Control Groups

Experts (n = 14) Controls (n = 14)

Task Mean SD Mean SD

EQ 30.7 14.3 24.6 19.4

EC 25.8 2.9 25.7 5.5

IRI (PT) 17.8 4.4 16.9 3.8

IRI (EC) 21.8 3.6 20.1 3.5

IRI (PD) 13.1 4.4 13.7 5.0

IRI (FS) 17.6 3.8 15.6 7.8

SPQ 5.5 0.7 5.5 1.2

PAIN 4.1 1.7 6.5 1.2

UNPL 3.5 1.9 6.5 1.4

The following abbreviations are used: empathy quotient (EQ),

emotional contagion scale (EC), interpersonal reaction index (IRI),

perspective taking (PT), empathic concern (EC), personal distress

(PD), fantasy (FS), situational pain questionnaire (SPQ), pain inten-

sity ratings (PAIN), and unpleasantness ratings (UNPL). Ratings of

pain intensity (p = 0.00019) and unpleasantness (p = 0.00007); under-

lined rows report significant difference between the expert and

control groups.

Figure 1. Differential Neural Activations between the Experts and ControlsWhenWatching Body Parts Being Pricked by an Acupuncture Needle

(A) Participants from the control group activated bilateral insula, PAG, ACC, and SMA, whereas participants from the expert group activated right

inferior parietal lobule and medial prefrontal gyrus.

(B) Compared to the expert group, participants from the control group scored significantly higher on pain intensity and unpleasantness ratings.

(C) Parameter estimate graphs show signal change in the insula and medial prefrontal cortex for each condition in each group. When watching

acupuncture procedures, stronger activation was detected in the anterior insula in the control group, whereas the experts showed stronger

activation in the medial prefrontal cortex. When watching a Q-tip, there is no such double dissociation.

The Regulation of Pain Empathy1709


personal reflectioncontinuing study vacation

and the advantages of an invested, disconnected colleague...

other beneficial disconnections


1 illusion that subjective perceptions or judgments are objective observations or interpretations that reasonable colleagues would share.

2 self-serving situational attributions rather than disposition at-tributions for explaining mis-steps after things go wrong.

3 confirmation bias >perseverance of erroneous beliefs, >seeking out supportive colleagues >failing to check for dissenting viewpoints.

PERSPECTIVEPracticingMedicinewithColleagues: Pitfalls from Social PsychologyScienceDonald A. Redelmeier, MD, FRCPC, MS(HSR), FACP1,2,3,4,5 and Lee D. Ross, PhD6,7

1Department of Medicine, University of Toronto, Toronto, Canada; 2Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada;3Institute for Clinical Evaluative Sciences in Ontario, Toronto, Canada; 4Centre for Leading Injury Prevention Practice Education & Research,Toronto, Canada; 5Sunnybrook Health Sciences Centre, G-151, Toronto, Ontario, Canada; 6Department of Psychology, Stanford University,Stanford, USA; 7Stanford Center on International Conflict and Negotiation, Stanford, USA.

This perspective reviews three pitfalls from psychologyscience that can distort clinical assessments and contrib-ute to interpersonal conflicts. One pitfall is the illusionthat one’s own subjective perceptions or judgments areobjective observations or interpretations that reasonablecolleagues would share. A second pitfall involves self-serving situational attributions rather than dispositionattributions for explainingmissteps after things gowrong.A third pitfall is confirmation bias that leads to a perse-verance of erroneous beliefs, a tendency to mostly seeksupportive colleagues, and a failure to check for dissent-ing viewpoints. An awareness of these three pitfalls mayhelp clinicians improve patient care when practicing withcolleagues.

KEY WORDS: medical error; fallible reasoning; judgment and decisions;

illusion of objectivity; situational factors; confirmation bias.

J Gen Intern Med 34(4):624–6

DOI: 10.1007/s11606-019-04839-5

© Society of General Internal Medicine 2019

INTRODUCTION

It is easy to recognize cognitive and motivational biases thatproduce conflict in political discourse. While not a subject ofregular news-media coverage, the same interpersonal conflictsmay compromise clinicians providing daily medical care.Effective practice demands that clinicians have some insightinto human motivations and behavior.1 Good clinicians mayalso know a great deal about the nature of their own colleaguesand professional networks. However, some pitfalls aroundinterpersonal interactions are subtle and easily go unrecog-nized. These pitfalls have been uncovered by provocativeresearch in psychology, particularly social psychologyscience.2

Social psychology science examines how people perceive,think about, and act toward other people. 3 Insights from socialpsychology can be vital for collaborating with medical col-leagues; moreover, the insights can also help illuminate com-mon pitfalls. A failure to appreciate such insights may not

matter when interpreting a kidney biopsy, for example, but alack of such insights can frustrate efforts in organizing peopleto perform the kidney biopsy in the first place. More generally,successfully initiating a diagnostic test, surgical procedure,referral consultation, or follow-up visit requires knowledgeabout the way people make judgments and decisions whenthey interact with each other.A comprehensive list of social psychology science might

include studies on motivation, incentives, self-control, forget-fulness, conflicts, idiosyncratic personalities, diffusion of re-sponsibility, and thoughtless habits.4 Herein, we do not at-tempt to review that vast literature on diverse sources ofinterpersonal conflict; instead, we discuss three specific pit-falls that can comprise effective interpersonal interactions(Table 1). Each has counterintuitive features, is relevant topatient care, has been validated in highly replicated research,and appears in standard psychology textbooks. However,these pitfalls are rarely discussed in medical training orMEDLINE searches.

The Objectivity Illusion

Medical practice, like all professions, requires judgmentsbased on perceptions. Clinicians need to trust their senses,show confidence, and act decisively. They do so, however,with a conviction of personally seeing the world objectivelyand believing that people who disagree must be less informed,rational, or objective. This illusion of objectivity means, forexample, that a difference in opinions between a clinician anda hospital administrator is usually ascribed to a deviant biassuch as self-interest, external pressures, or desire for institu-tional approval. While some of these factors may partiallycontribute to disagreements, the individuals may fail to ex-plore the real sources of information in a more open-mindeddialogue.A consequence of the objectivity illusion is a tendency to

overestimate the extent to which personal views are widelyshared. One classic study, for example, asked university stu-dents (n = 80) to estimate whether nuclear weapons would beused in warfare in the next twenty years and to estimate theconsensus of their peers.5 Those who said Byes^ tended tothink their peers would similarly say Byes^whereas those whosaid Bno^ thought only a minority of their peers would instead

Received July 4, 2018Revised October 25, 2018Accepted January 9, 2019Published online January 31, 2019

624

JGIM


thank [email protected]

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