An Intensive Care Unit (ICU) is a demanding and stressful work environment for healthcare professionals. Long working hours, challenging workload with life-threatening conditions of patients, and managing conflicts with co-workers and patients’ relatives might result in work-related stress among ICU professionals.1,2 There is a growing interest in promoting healthcare professionals’ wellbeing. Resilient, healthy, and engaged healthcare professionals are more productive and less likely to leave their job or be off sick.3 However, what does ‘wellbeing’ mean and how is this linked to work-related stress in an ICU and influence patient safety? Therefore, the focus of this paper is to address the concept of wellbeing, to described how the stressful ICU working environment influence the wellbeing of health professionals, and to discuss how this situation jeopardizes patient safety.

Wellbeing is the keyword in the World Health Organization’s (WHO) definition of health: “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”.4 In particular, the WHO identifies mental health as “state of wellbeing in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community”.4

Wellbeing is a complex concept, which varies according to the context and the individual.5 It relates to a wide range of dimensions (Fig. 1). More than twenty years ago, Ryff et al.5–7 started to study wellbeing. They developed a six-factor model of psychological wellbeing which determines six factors that contribute to an individual’s psychological wellbeing, contentment, and happiness. This model of psychological wellbeing differs from past models in one important way: wellbeing is multidimensional, and not merely about happiness, or positive emotions. According to this model, psychological wellbeing consists of:5

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  Self-acceptance: a persisting positive and acceptant attitude toward oneself.

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  Personal growth: the insight into one’s own potential for self-actualization.

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  Purpose in life: goals and beliefs directing one’s meaning in life.

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  Positive relationships with others: having satisfactory personal relationships.

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  Autonomy: self-determination as guided by one’s internal standards.

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  Environmental mastery: ability to manage or create a suitable environment to accommodate personal needs and values.

Figure 1.

Dimensions of wellbeing.

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Wellbeing should include a social dimension since our personal (psychological) wellbeing depends on the social context and our social connections.8 Coexistence in our work and life, traditions and beliefs are important for our social wellbeing (Fig. 2).9 Both psychological and social well-being are essential conditions for optimal functioning. Together they determine how we feel about ourselves and life in general, our emotional wellbeing. Emotional wellbeing means using strengths rather than focusing on solving problems or weaknesses.8–10

Figure 2.

Wellbeing at work. Beyond personal development and work-life balance, many gears must intertwine to create a wellbeing culture in the professional environment.

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Healthcare professionals working in the ICU often deal with patients suffering from life threatening illness and their relatives struggling between hope and loss. Consequently, the role of healthcare professionals, during the patient’s illness can be challenging for themselves.11,12 In addition, working within a team of people with different personalities, competencies, and specialties, with constraints and demands, can contribute to a working environment that is prone to conflicts and disagreements.13 All this, emphasizes the ICU as a stressful work environment. It has been described that ICU healthcare professionals could be emotionally affected by several factors14–17 (Table 1). Thus, working in the ICU threaten the wellbeing of ICU nurses, intensivists, and allied healthcare professionals.

Individual responses to stress may be manifested as physical symptoms such as headaches, sleep disorders, low back pain and stomach problems or as mental responses such as being irritability or hostility, loss of concentration, low self-esteem, emotional instability.18 However, these are non-specific symptoms that do not enable the identification of the source of stress and therefore limit effective coping mechanisms or the development of preventive strategies for this ongoing process.19,20 In short, the stressful environment of the ICU has negative consequences on health professionals’ wellbeing.

Apart from the large amount of literature on mental health and wellbeing within ICU settings published in recent years, the impact of the COVID-19 pandemic on healthcare professionals working in ICUs is also reflected in accentuated staff shortages and job leaving intentions.52,53 The prevalence of impaired psychological wellbeing, as well as symptoms of burnout and job dissatisfaction, was already high before the surge of COVID-1954,55 and was understandably exacerbated by the pandemic and its subsequent waves.55–57 In any case, COVID-19 warrants a separate chapter on wellbeing. The COVID-19 period has very specific factors of ICU working conditions from the scarcity of resources58,59 to the fear to get infected and to infect their loved ones, or the isolation between patients and relatives60 among others.

In a work context, resilience is the ability of workers to adapt when faced with difficulties (work-related stress). It is a necessary quality to promote wellbeing when facing the challenges of life and work.61 Resilience is a learned skill, which encourages investment in resilience training. Resilience training helps to bounce, and not break.62 According to the Mayo Clinic, the most effective method to enlarge personal resilience is training attention and awareness. Becoming more intentional and purposeful will decrease negative thoughts and draw attention to what is most meaningful.63 Similar resilience training could be useful for ICU healthcare professionals to adaptively cope with work-related adverse conditions and stress, although research is still lacking to support this idea (Fig. 3).

Figure 3.

Work engagement, a counterbalance to work-related stress.

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To prevent migration of specialist staff from the ICU, it is of utmost importance to promote a proactive approach to wellbeing at work. This should be fostered by providing supportive organizational structures.64,65

In this respect, it is useful to differentiate between preventive approaches:

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  Primary prevention aims to prevent health impairment and sick leave before they occur. This is achieved by avoiding exposure to (chronic) stressors and increasing resilience to work-related stress. Examples include enforcing safe and healthy practices (i.e., reasonable work schedules), enhancing interdisciplinary communication (regular moral counseling, team huddles and day starts),66 and educating about healthy and safe habits (i.e., regular exercise, relaxation techniques). A positive team culture and collegial support are needed to be open on the stressful situations and work environment of the ICU.67 In addition, the use of new tools to promote teamwork, communication, and patient safety such as real-time randomized safety audits could improve quality and safety in critically ill patients.68 Above that, addressing autonomy in work or supporting positive relationships among team members are important aspects.

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  Secondary prevention seeks early detection of (dis)stress symptoms. Examples include training employees to better handle their work situation while providing them with resources to optimize their coping abilities and to enhance their resiliency to stress, using apps monitoring stress and vital signs 24/7, or self-report screening instruments.

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  Tertiary prevention is defined as the treatment of individuals who are already highly stressed. It consists of providing ICU healthcare professionals with opportunities for treatment and recovery and the necessary services and resources to ensure their effectiveness.

Recommendations on preventive strategies on how to relate to these aspects are often missing. Some studies measured the effect of interventions such as different working schedules of intensivists, educational programs on emotional distress, improvement of elements of family-centered care and communication skills.68–72 Other studies suggested preventive strategies, ranging from improving the working environment, changing the composition of teams to include more women, developing teamwork and regular job rotation.73–77 However, most interventions showed only a trend toward improvement and few programs resulted in statistically significant change. The implementation of a number of strategies, such as an active and intensive communication strategy regarding end-of-life care in the ICU, was associated with significantly lower rates of burnout and depression after some of these interventions.78 Further examples of interventions to support wellbeing of ICU health professionals are presented in Table 2.79

To improve wellbeing of healthcare professionals working in ICU, it is not enough to help only those who are perceived to be under too much stress. Stress reactions are early indicators of an imbalance in the physical or emotional load and in the individual's ability to adapt to challenging situations. Positive and flourishing individual conditions are not only related to personal wellbeing but are also helpful for improving work performance and team spirit. This will ultimately improve quality-of-care and patient safety. However, changing the wellbeing of ICU healthcare professionals also requires addressing organizational wellbeing. Even if the consequences for healthcare professionals and patients can be well described and there is currently solid evidence, the solution for day-to-day work remains unclear. In any case, organizational strategies, such as structural changes, stress debriefings and ethical support in the ICU, can positively influence wellbeing at work as well as patient safety. This will ultimately improve quality-of-care and resilience of the team.

ERR and KF wrote and prepared the manuscript. MMCVM and JL supervised and approved the final version of the manuscript.

The authors have no conflict of interest to declare regarding this article.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.