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Distress Contagion: Interpreting Health Care Team Response to ICU Stressors
Abstract & Commentary
By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.
Synopsis: When events were assessed by one team member as highly stressful, individual distress was highly contagious, impairing performance of the entire multidisciplinary team.
Source: Piquette D, et al. Stressful intensive care unit medical crises: How individual responses impact on team performance. Crit Care Med 2009;37:1251-1255.
The ICU is commonly viewed as a stressful environment. While common, stress responses are likely to vary over time, between individuals, and as a result of the context in which they occur. This study was prompted by the authors' desire to better understand factors that influence team function during the events that surround a medical crisis, defined as an event that requires the immediate response of multiple ICU team members as a consequence of acute patient instability. From interviews of ICU clinicians, the authors attempted to determine: 1) the effects of stress on individual performance during a medical crisis; 2) specific behaviors that positively or negatively impact team performance; and 3) potential strategies to manage such events more effectively.
A total of 32 participants were recruited from medical-surgical, cardiovascular, and neurosurgical ICUs in a university-affiliated institution, and interviewed using a semi-structured format. Participants included ICU attending physicians (n = 6), residents (n = 7), nurses (n = 14), and respiratory therapists (n = 5). Not surprisingly, the need for quick decision making and the high stakes involved were cited as common stressors during a medical crisis. However, those interviewed described a number of resources available to meet such demands. Most crises were described as challenging rather than threatening, able to be brought quickly under control and, as a result, not perceived as distressful or problematic.
Several conditions were cited as leading to situations that were perceived as highly stressful. As might be expected, greater stress resulted if the patient did not respond and continued to deteriorate. High levels of stress were also reported if any member of the team appeared unable to appropriately fulfill his or her role or displayed an "emotional outburst." Such behaviors were perceived as creating a phenomenon the authors termed "disruptive contagion" because it spread rapidly, disrupting functioning of the team. To resolve this problem, participants recommended attempting to refocus on the patient-related goals and guarding against displays of excessive emotions, particularly displays of anxiety.
Several recent studies have commented on the high prevalence of symptoms of burnout and acute post-traumatic stress disorder (PTSD) among ICU clinicians. These findings are concerning in view of the increasing need for critical care clinicians. There are many commonly cited reasons that make the ICU environment one that exposes clinicians to high stress levels, but limited knowledge in regard to what to do to change this situation. The present study examined one aspect that may contribute to stress and burnout — ICU team response to a medical crisis.
The finding of most interest was the highly stressful consequences that were perceived to result from emotional outbursts during the management of such events. Termed "disruptive contagion" by the authors, such events triggered concerns regarding the ability (medical, nursing, or respiratory care) to provide optimal patient care, a critical factor in an environment where team members strongly depend on each other. Stress levels quickly escalated, particularly if the team leader was the one exhibiting a strong emotional reaction. This observation is important because it identifies a potentially modifiable risk factor.
For some time, anesthesia providers have used training in Crisis Resource Team Management to perfect their skills during unexpected or uncommon crisis events. Team function is stressed with participation by anesthesiologists, fellows, nurse anesthetists, and nurse anesthesia students. Implemented using high-fidelity human simulation, such training allows one to perfect skills in a safe environment with the benefit of debriefing. Key behaviors that are reinforced during such training include communication, leadership, optimal use of resources and information, and continuous reassessment to avoid inappropriate decision making. In addition to training in crisis management, such programs could be designed to incorporate actors whose behavior is designed to be profoundly disruptive with the goal of learning not only the technical skills required to adeptly manage such events, but also the behavioral skills needed to provide leadership and inspire confidence in others during such events.