Stress in critical care nurses: a policy perspective

It is no news that critical care is intensely stressful for those hospitalized, their families and health care providers. Burnout and mental health morbidity are common among critical care nurses (Moss et al., 2016), and despite lack of data, the question of potentially increased suicidal rates among nurses has been raised (Davidson et al., 2018). Remarkably, despite the extent and urgency of the problem, policies targeting employees' mental health in the health care sector are non-existent in many countries. We propose that this may be due to the way the problem is conceptualized and defined. Problem definition is fundamental in policymaking (Pal, 2014). In this editorial, we will discuss issues of critical care nurses' stress from a policy perspective. We will argue that health care providers' mental health is inexorably linked to intensive care unit (ICU) patients' and families' psychological and physiological outcomes. With the rising use of ICU services and the rising severity and age of critically ill individuals, this problem is bordering a major public health issue. Reports of critical care nurses' stress are dated as early as the 1970s, and they describe challenges strikingly similar to contemporary problems (Cassem and Hackett, 1975). Yet it was only recently that a Critical Care Societies Collaborative (CCSC) acknowledged burnout as a pervasive problem in critical care and developed a call for action (Moss et al., 2016). Burnout is believed to be triggered by a discrepancy between expectations and actual job requirements (Consiglio et al., 2014). Burnout is an important stress-related syndrome, but only one aspect of the many challenges facing critical care nurses. Post-traumatic symptomatology, depression, anxiety-related somatic symptoms, moral distress and vicarious stress are common in critical care nurses (Karanikola et al., 2015). These have also been linked to compromised patients' outcomes, occupational injuries, lower hospital profitability and higher employee turnover (Stone and Gershon, 2006). Indeed, the ‘Working Together for Health’ emphasized the global shortage of nurses, due to stressful work conditions (WHO, 2006) and the World Mental Health Day in 2017 focused on succeeding premium mental health in the workplace (WHO, 2017a). WHO has acknowledged the importance of psychosocial hazards, such as shift work and stress, which are especially relevant to critical care nurses (WHO, 2017b). A key factor in policymaking is the definition of the problematic situation (Pal, 2014, p. 97). The way we define a problem will also dictate the nature and effectiveness of solutions. We will use Rochefort and Cobb's (1993) framework, which addresses causation, nature of the problem, population, ends-means orientation and solution, to discuss current conceptualizations of critical care nurses' stress. The first step is to elucidate current understandings of the causation and origins of the problem. Here the question of culpability becomes important. Is the problem attributed to individual-personal versus impersonal-external causes? Although it is acknowledged that, at least for burnout, risk factors include personal characteristics, organizational factors, working relationships and end-of-life care (Moss et al., 2016), the bulk of interventional and correlational studies for critical care nurses' stress address personal characteristics. These include nurses' demographics, qualifications, resilience, type of personality, coping mechanisms and emotional regulation (Barr, 2018; Cho and Kang, 2017; Mealer et al., 2017; Saedpanah et al., 2016). Interventional studies addressing system-wide issues are very scarce. Therefore, about the question of responsibility, despite a rising awareness on the role of organizational factors (American Association of Critical Care Nursing, 2016), a common view reflected in research efforts appears to be that the problem is attributed mainly to nurses themselves, rather than the system of critical care. It is probable that this perception will have to be challenged for effective policy analysis. For example, the Action Collaborative on Clinician Well-Being and Resilience (ACCWR) of the National Academy of Medicine (NAM), USA, has taken a more balanced view aiming to identify evidence-based solutions to improve well-being in clinicians at both the system and individual levels. Of note, research efforts to build resilience in critical care nurses are worth-noting (Mealer et al., 2017). Resilience, as a state of mental toughness, is a favorable personality trait when dealing with intensely stressful situations. For instance, resilience is sought to be developed in army soldiers (Morgan et al., 2018), based on the fundamental understanding that war is bad and will never change. However, critical care is and should not be a state of war. With regard to severity and incidence, research literature is unanimous in that the problem is very severe, prevalent and with increasing incidence. Recent evidence highlights a range of severe stress-related morbidity in critical care nurses, including mental distress related to workplace originated traumas, i.e. secondary traumatic stress syndrome (Beck, 2011; Dominquez-Gomez and Rutledge, 2009; Mooney et al., 2017); increased frequency of morally distressing experiences (Austin et al., 2016; Haikali et al., 2016); and severe degree of professional burnout (Alexandrova-Karamanova et al., 2016; Montgomery et al., 2015). At the same time, the main causes of ICU nurses leaving the profession are severe sleep disturbances and depressive mood (Lai et al., 2008). A recent review revealed that approximately one of five ICU nurses experience severe psychological distress, a frequency of depressive and anxiety symptoms ranging from 11% to 33% and frequent post-traumatic stress disorder (PTSD) symptoms (Karanikola et al., 2015). Moreover, both incidence and severity of this problem are expected to rise, alongside with the expansion of ICU beds and severity of critically ill patients. Based on Rochefort and Cobb's (1993, p. 66) definition of crisis as ‘a situation where corrective action is long overdue and dire circumstances exist’, critical care nurses' stress qualifies as a crisis situation in need for immediate policy action. The question of novelty is also important. When a problem is described as novel it can win attention, but as novelty wanes momentum for policy is lost. To this end, initiatives such as the CCSC on burnout and the ACCWR are important in publicizing the issue, especially if they can influence policy in a timely manner. For example, ACCWR is a network of more than 50 organizations, including the American Association of Critical-Care Nurses, dedicated to work against work-related distress in clinicians. ACCWR's goals are: (a) to expand knowledge on challenges against clinicians' well-being; (b) to increase awareness on clinicians' work-related stress and subsequent mental distress; and (c) to generate evidence-based, multidisciplinary strategies towards enhancement of patient care by caring for the caregivers (NAM, 2017). Proximity describes how relevant a problem is for a person's interest – in other words, why should the public worry about critical care nurses' stress? The truth of the matter is that a considerable percentage of individuals will have at least one ICU stay in their life-time. In Canada, 11% of adult hospital stays include time in an ICU (Canadian Institute of Health Information, 2016); whereas, in the USA 20% of acute care and 58% of emergency department admissions result in an ICU admission (Society of Critical Care Medicine, 2018). In Europe, there is a wide variability among countries (Rhodes et al., 2012). These data, coupled with the aging population and increasing severity, point to an expected rise in ICU use. Reduced quality of care, lower patient satisfaction, medical errors, higher rates of health care-associated infections and higher mortality rates are some of the better-documented consequences of nurses' distress, which can also affect post-ICU quality of life and recovery (Moss et al., 2016). Moreover, high turnover of critical care nurses due to stress (Cummings, 2011) accounts for staff shortages, which also affect patients' outcomes. Considering the effects on those individuals' families and work environments, the societal and health care impacts of any compromise in critical care nurses' ability to provide excellent care are tremendous. Perceptions regarding the group afflicted by a problem largely define if this problem will be given priority or solution. This includes public views and professional views, especially of a professionally dominant group. Traditionally, physicians' views and priorities have led health care policies (Black, 2001). Also, commonly, the majority of critical care nurses are women; whereas, only 17%, approximately, of ICU physicians are women (Hawker, 2016). There is a lot written on the stigmatization and discrimination relating to women's mental health. A gendered picture exists with women being labeled ‘emotional’ and ‘sensitive’ (Küey, 2010). Underlying this issue is the important question of culpability (Rochefort and Cobb, 1993). Put another way, can the problem be helped or is it inherent to the affected population? Considering this matter, the partnership among nurses' and physician associations in initiatives addressing mental wellness in health care is a very important step towards overcoming barriers related to gender biases. In policy, sometimes, the important issue is not whether a specific solution will be effective, but whether the solution is acceptable, especially in a context of competing fiscal demands. For example, in the case of critical care, solutions that build ‘toughness’ of individual nurses may be viewed as more acceptable, compared with solutions that seek to re-engineer the ICU environment, including physical, inter-personal and cultural components. The pervasive ICU culture views care as a fast-paced, technically driven, linear problem-solution process; therefore, it may favor solutions that can mechanistically address a problem over holistic approaches. The case of ICU delirium is an example of how culture can affect problem definition and preferred solutions. ICU delirium has been identified as a serious problem for at least 40 years (Trogrlić et al., 2015) and despite failures to either treat it or prevent it pharmacologically (Al-Qadheeb et al., 2016), efforts with combinations of anti-psychotics and sedatives persisted for decades. Eventually, it became apparent that less-invasive, non-pharmacological and more holistic modes of prevention are more effective; however, ICUs worldwide still struggle to create a culture permissive of those approaches (Trogrlić et al., 2015). With regard to policy-making in critical-care nurses' stress, the case of ICU delirium can not only provide a very useful metaphor, but can also be viewed as a concurrent exemplar, one sharing most of the context and antecedents of critical care nurses' distress, but afflicting a different, nevertheless related, population. ICU delirium is linked to nurses' psychological morbidity, i.e. burnout, moral distress and anxiety; so a vicious circle seems to perpetuate among critically ill patients' distress, families' suffering and clinicians' psychological burdens. A healthy work environment for ICU personnel is inevitably interrelated and contingent upon a healing environment for patients and families. Therefore, advocacy for critical care nurses' stress must be linked to advocacy for improving the healing aspects of the ICU milieu. Descriptions of solutions are inherent in problem definition for policy-making. The most basic concern at this stage is whether there are solutions available, or whether it will be a waste of effort to address a problem, given a lack of solutions. Although most would agree that sustaining a healthy work environment is central in countering ICU stress, there is a striking lack of evidence from interventional studies (Moss et al., 2016), and most of the evidence is burdened by a limited view of the scope and origins of the problem. This is not necessarily a bad thing though. Based on the analysis above, it is clear that more conceptual work is needed in defining the problem, before we can devise and test effective ways to address it. However, the relation between research evidence and policy is seldom linear, for reasons including politics, costs, consensus and the social environment (Black, 2001). This is important for nurses to understand. Strong evidence will not necessarily result in rational and effective policy. Critical care nurses need to actively advocate and influence policy to promote a healthy and healing work environment. To sum up, critical care nurses' stress has reached proportions of crisis and it can be viewed as a significant and rising public health concern. A tendency to attribute responsibility to the afflicted parties, as well as the pervasive ICU culture and gender biases, as well as lack of empirical solutions and differing priorities may obscure the urgency and nature of the problem. More conceptual work on problem definition is needed before effective strategies can be developed. However, definition of the problem is not but one of several intertwined components of policy. Defining which goals should be achieved, the instruments through which the goals can be met, the actors and related policy frameworks are other necessary elements (Pal, 2014, p. 11). Obviously, different actors will have different goals based on differing priorities and values. Which are the actors in the problem of critical care nurses' stress? The Critical Care Societies Collaborative (Moss et al., 2016) identifies the following groups: (a) critical care professionals and their families, (b) ICU-based leaders and hospital administrators, (c) funding agencies, (d) professional societies, (e) academic institutions and (f) patient advocacy groups. Based on the analysis above, we will argue that the central actors are critical care professionals and critically ill patients and their families, because they have the higher stakes for policy. Patients' and families' involvement in influencing policy and a patient-clinician consensus on goals and instruments will be imperative in effecting policy-making to address critically ill patients' stress.

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