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Intensive care unit (ICU) clinicians pride themselves on their ability to care for others, even at the expense of caring for themselves. Kyle B. Enfield, MD, FSHEA, FCCM, was joined by Emily K. Valcin, DNP, RN, FCCM, during SCCM’s 2023 Critical Care Congress to discuss ICU clinician well-being and the importance of self-care.
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Dr. Enfield: Hello and welcome to the 2023 Critical Care Congress edition of the Society of Critical Care Medicine Podcast. I’m your host, Kyle Enfield. Provider well-being is a topic deeply important to the future of medicine, touching everything from patient outcomes to staffing levels. At our Sunday plenary session, Kristin Flanary reminded each of us that before we are critical care providers, we are humans. Today, I’m sitting down with Kate Valcin, DNP, RN, FCCM, to discuss ICU clinician well-being. Ms. Valcin is director of critical care and nursing at the University of Rochester Medical Center in Rochester, New York. Ms. Valcin, before we start, do you have anything to disclose?
Ms. Valcin: I do not have anything to disclose.
Dr. Enfield: As I mentioned in the opening, one of the really impactful statements over an incredibly impactful plenary session yesterday morning was this simple statement that has so many levels about each of us being human. Not only for the fact that we can connect with other people as humans when we’re in the ICU, but that we are humans taking care of other humans, and that creates so many factors for us. But I think this concept of well-being is difficult for some of us to wrap our hands around because it can mean so many different things. When we’re talking about ICU provider well-being, how do you think about that?
Ms. Valcin: That is a really interesting and challenging question. As a member of the task force, I had the honor to serve with a group of 10 individuals. We probably spent the first half of our work trying to actually define: What is well-being? You can’t create a resource to promote well-being if you don’t have a definition for what well-being is. Sometimes it’s resilience, sometimes it’s workload balance, sometimes it’s work-life balance, sometimes it’s being part of a community or mattering. When we thought about well-being, particularly in the light of the work that we were doing, the way that we define it is a sense of control and joy in your work, having the support and resources necessary to do your work and to do your work well and to have the ability to be an integral member of a moral community.
Dr. Enfield: Yeah. That concept of control, I think keeps coming up for so many of us, and we really see that even recently, in the New York City nurses strike, it wasn’t so much the money that they were striking over but that sense of control. What that makes me think about is, when we think about what we can control in our ICUs, what does that really mean? Because there are just some things that we can’t control. We can’t control the patients that are rolling through the doors, we can’t control that we are going to need to be staffing 24/7, that we can’t work from home like so many of our peers. What do you think that really means to each of us?
Ms. Valcin: In the end, the only thing that we can control is ourselves and the way that we choose to participate and interact with our teams. I think what we have control over in critical care is our culture, our work environments, and we have control of our voice. I think that that’s something that we don’t use enough. A lot of the pieces of this toolkit are really tools to articulate better what are the things that we need as critical care clinicians, so that we can use our voices to promote our own well-being rather than feeling helpless or out of control in a particular situation.
Dr. Enfield: You’ve mentioned what the task force was working on, but why do you think it’s important for critical care clinicians to really engage in this concept of well-being right now?
Ms. Valcin: I think that that’s multifactorial at the very most basic level because we’re humans, and we’re humans that have been through an incredibly hard couple of years. We work in critical care because we want to help people and we want to take care of people, but we haven’t been taking care of ourselves, or we haven’t been taking care of ourselves well. What we’re seeing is, in every type of clinician role in our critical care environments, people are leaving critical care. They haven’t been taking care of ourselves. We haven’t had a culture of taking care of ourselves, so we’re losing the ability to take care of others because we aren’t taking care of ourselves. At the very core of well-being, there’s this idea of, we need to take care of ourselves so that we can be well, so that we can help others become well again.
Dr. Enfield: That concept of culture is really interesting. I wondered if you could maybe talk about what you and the task force thought about when you were thinking about why our critical care culture didn’t evolve to include well-being. How do we get to this place? What was going on in our society or within our units that really made us move to this point where we now need to have a task force to talk about well-being?
Ms. Valcin: One of the things that we talked about a lot is that we are problem solvers and brainstormers and people who have incredible ability to figure things out. We’ve often solved the problem without thinking about why it was the problem or what were the roots of the problem. We’re continually moving forward without necessarily taking that pause or that break to say, Maybe if I fix the problem upstream, I won’t have to keep doing this workaround that’s really troublesome every single day because I can just do this workaround and that’s faster than maybe taking that time to figure out that upstream problem.
I think that, in critical care, we carry a lot of challenges in the sense that our patients are most at risk for complications. There’s a lot of quality improvement focus on our care. As a nurse, I hear a lot about, Well, all of the central line infections are in critical care, all of the catheter-associated UTIs are in critical care, the pressure injuries are in critical care. What’s going on? We have extra things to think about that maybe other pieces of the hospital or other departments in the hospital have to think about just in a different way.
Dr. Enfield: Yeah. The quality improvements issues really hit home for me because it is the thing that has driven so much of my research, but it is also the thing that I hear causing a lot of distress and challenge for our bedside nurses because there is that weight, that burden that comes with that. What are some things that people can take away for how we look at that burden that’s really put on us both internally because we want what’s best for our patients but also externally because our hospitals, our healthcare systems, want these metrics to look great for various reasons?
Ms. Valcin: I think that, going back to some of our earlier conversation, we can be responsible for our piece and we can’t be responsible for other people’s pieces. Some of it is really being able to be centered in the moment and say, I’m going to focus on the things that I can control and manage today that are within that scope of my control, but I’m going to not withhold the information from others who have the role or the job of extending my work or expanding my work. I’m going to do what I can today, but then I’m going to let my leadership know, I’m going to share what the barriers are, I’m going to share what went really well today and what was really able to facilitate care so that we can start replicating some of those things again.
Dr. Enfield: One of the things that the task force that you were on produced was the ICU Well-Being Toolkit. Many of the members of the Society of Critical Care Medicine received an email about this. Actually, we all did, and hopefully lots of people looked at it, but I think a lot of people also probably get a lot of emails and sometimes things get missed. What is that toolkit and why should people open it up?
Ms. Valcin: I think the first thing to know is that we had a conversation early on where we all acknowledged that we’ve gotten a lot of emails about how we need to change our personal behavior or things as individuals that we should be doing—sleeping, eating, resting, taking lunch breaks. Sometimes it’s deep breathing and yoga and exercise and all things that are really important on an individual basis, but we thought that there was enough information and that we all know that we’re supposed to be doing those things. So we very specifically made this toolkit not those things. This is not a toolkit about personal resilience. If you’re someone who wants more information on personal resilience, you can Google it, you can find lots of information out there.
What we really chose to focus on are, what are the things that are unique and special about being a practitioner in critical care? What are the things that are really challenging right now in critical care that were thematic influences on well-being as we talked in our multidisciplinary group? Then, also recognizing that we’re all tired, so sifting through all of the information to know, where do I start? If you have a team that wants to focus on well-being, knowing where to start can be just as challenging as actually doing the work.
We fondly call the toolkit the Choose Your Own Adventure Well-Being Toolkit because what we really wanted to build was a resource to help individuals who care about the well-being of their team prioritize what are the challenges. If you choose to download the toolkit, you’ll see that it’s essentially questions focusing on workload and job demands, efficiency, control and flexibility, work-life integration, social support and community at work, organizational cultures and values, meaning, and ethical community. As you answer those series of questions on a Likert scale, you’ll end up with a priority score. Of those eight areas that I mentioned, you might find, OK, these are the top three. Then, when you click on those areas, we actually developed resources specifically targeted to solve those problems.
If you’re looking for efficiency and resources as the focus of your initial well-being activities for your team, then that’s what those resources are. They’re all amazing resources. Some of them are very practical, some of them are links to articles so that you can find the data that you need to share with leaders and others related to best practices for workload and efficiency and things like that.
Dr. Enfield: If I understand you right, each ICU, each person, may have a different adventure that they’re going to be on. It’s not that this is a one-size-fits-all toolkit, that you’re going to remind us all that we need to box breathe today.
Ms. Valcin: That is exactly correct. We know that every ICU is different. Every challenge is different. Within an institution, every ICU has its own culture and personality and opportunity to improve well-being. We were really trying to be inclusive and make this a toolkit that worked for everyone, but not by telling everyone to do the same stuff. You have the ability as you fill out those questions to filter and then to have that support in prioritizing, here’s a place to start.
Dr. Enfield: That sounds amazing. I know that you worked on this, and I also know that Dr. Beth Epstein, who I know well, was a part of this task force, but could you share who were the people that came up with this toolkit?
Ms. Valcin: Certainly. There was a group of 10 of us. It was a mix of providers, respiratory therapists, nursing, and pharmacists, representing not all of the roles on our teams, but many of them. We were meeting monthly or sometimes twice a month for a period of six months, really focusing on, what is it like to be a practitioner, what are those impacts of well-being? I do want to give a shoutout to Beth, who’s not able to be with me here today, but also Ankita and David and Mark and Carsten and Andrea and Pamela and Joanna and Kelly, who were all important team members and contributed many hours of, this is what worked at my institution, this is what I’ve seen, this is what I’ve heard other people doing, so that we could include them in the resources of the toolkit.
Dr. Enfield: When you created this toolkit, you talk about these resources. Is there an evidence base? Because we’re ICU providers, we like to have clinical evidence to drive our care. Is there an evidence base that led to these resources or are these just things that you found on the web? How did you find and pick the resources to include?
Ms. Valcin: I would say it’s a balance. We certainly included some of the best evidence in the literature. I would say that this toolkit is also being developed. We spent our initial first six months really getting it launched, but it’s our full intention to continue working. If there’s anyone listening who says, Oh my goodness, I have something that I think should be part of the toolkit because it’s this late-breaking piece of information or resource or evidence, please send it our way and we want to include the new things in the toolkit.
I think one of the things that is a little bit ironic is, as we were doing this work, we were looking at many well-being frameworks as our basis for what is the best evidence, what should we focus on in terms of well-being. But then, just as we were finishing up our work, the Surgeon General launched his workplace framework for workplace mental health and well-being and actually has, at the center of it, worker voice and equity and then five focus areas—protection from harm, connection and community, work-life harmony, mattering at work, and opportunity for growth. I think he may have been sitting in on our conversations because that national-level document with lots of evidence behind it actually aligns very well with the toolkit and the resources that we’re using.
Dr. Enfield: Lots of great resources there to pull from. I wonder how this well-being toolkit really interplays with the healthy work environment, because they seem very related along the same things, but they also sound slightly different. Can you talk a little bit about that?
Ms. Valcin: Sure. Of course, as a critical care nurse, I’ve had the healthy work environment standards really ingrained in a lot of the work that I have done. I think that there are certainly parallels with the work that we put together. I think that the healthy work environment is a little nursing-focused and nursing-centric, although it’s been utilized in many work environments. What we were really trying to do is be global and broad and inclusive. We didn’t want to use a framework that was embedded in one member of our team. We really wanted to use a framework that included everyone and was more universal. Certainly, there are elements of the healthy work environment. But, for example, communication is a piece of the healthy work environment that we don’t specifically call out in our toolkit, but every element of our toolkit involves some, here’s how you communicate the needs effectively, which is then, like I said, effective communication is one of the pieces of the healthy work environment.
Dr. Enfield: Are there any plans to take this work and roll up data from lots of different institutions into one big master document to see if there are common themes that we can work out as a society, or do you really feel that this is a grassroots local effort only?
Ms. Valcin: I think that it’s both. I think that we need to build the evidence that this toolkit has the right elements and prove that it is as inclusive as it needs to be. I think sometimes at my institution, we talk about evidence-based practice and then we talk about practice-based evidence, which is, you’re doing this and it’s working, so now we need to go back and do that measurement and understand the why of it. I would say this toolkit right now is in that practice-based evidence. It’s the practical things that we’ve all been doing but we do want to study further. We’ve been talking about publishing a white paper that really is all of the data and the why behind the work that we did, as well as what are the opportunities for further work. A lot of the well-being work that’s been talked about here at Congress is still siloed. I’ve heard talks on provider, I’ve heard talks on APP, physician, respiratory therapy, nursing, but we haven’t spent a lot of time talking about the team. We can’t fix the well-being of one role in the team in a silo, we have to fix it for everyone.
Dr. Enfield: Yeah, I found that super-ironic because I was looking through the things that were going to be presented, because as a society and as a group, critical care has always been about the interdisciplinary team. I wonder why you think that, when it comes to well-being, we’ve decided that we should throw away the interdisciplinary team and just focus on the one group.
Ms. Valcin: I think that we’ve chosen by accident or that was where inertia took us. I think that there are a lot of validated tools that have only been validated for a particular role because, honestly, the stress of the roles are different. What stresses out an attending is different than what stresses out a fellow or a trainee than an APP than a pharmacist than a nurse than whoever. We don’t have good tools for measuring our teams, we have good tools for measuring the pieces of the team. I think that’s what we have to figure out, is how do we aggregate and make sure that it’s measuring the things that are unique to critical care, the 24/7 piece of it, that nobody’s-going-to-work-from-home piece of it.
One of the things we’ve been talking about in my institution is, we have different practices for a nurse who doesn’t feel good, they just call in sick. A provider doesn’t feel good, they have to find coverage. There’s a whole different cultural norm around, what do you do if you’re sick? We’ve been having conversations about, the providers just see the nurses call in sick and think, wow, that would help my well-being if I could just call in sick. We need to think about all sorts of HR and culture and role structures for how do we manage that because of course the pool of nurses to backfill that sick person is very different than the pool of attending faculty who have just a different set of responsibilities.
Dr. Enfield: One of the things that I have been worried about over the last few months is that many of the structural things that have led to burnout within the ICU environment are not new. They’ve been there for a long time. Then we had this traumatic event for our world, and particularly for critical care providers, of the pandemic that has then brought the Surgeon General and this task force to work on something that was there. Yes, there are things that are a lot worse. But how do we utilize the momentum we have now to try to address things that were there before, the mental health issues just being one of them because we know that providers were at a higher risk for suicide than the rest of the public. But that’s just one aspect of this issue. Help me be hopeful that what we do today is not going to just get lost in a couple of months as we move on to the next thing. Because sometimes in the ICU, that’s what we do. This is the next fire I have to put out.
Ms. Valcin: Right. I think that we’re seeing changing expectations in our workforce globally that are going to force us to keep focusing on this issue. I think we’re seeing that there is a certain expectation of work environment that we don’t have in our hospitals right now, that the new generations entering the workforce expect. So we’re not going to be able to ignore this because we have to figure this out. It is a good thing to want to have time and a life outside of work, and we have to figure out how to create our workplace in a way that we can support the newer definitions of well-being, as well as maybe some of the older definitions of well-being. Part of what inclusion means is a space for everyone, right? We have to figure out how we can fit these different definitions of well-being, practices for well-being.
I think also there are things like what happened at the football game recently with Damar Hamlin that’s bringing to light the impact of being around critical illness and resuscitation and it’s causing, I think, those of us in healthcare to think about some of the things that we see differently. I think that we have to keep making space for that, but I think that we’re not going to be able to not make space for it because I think the members of our workforce see that other people are doing things a different way and are going to expect that from us.
Dr. Enfield: In a busy workday, what are your suggestions for an ICU to go through this toolkit? Should each provider do it separately and should it be done as a unit? How do you think that an ICU in my hometown can really leverage this toolkit?
Ms. Valcin: I think what I would recommend is, you need an interdisciplinary group, but that could just be two people because that would make it be interdisciplinary, right? You need a couple of people to have well-being as a focus, and I think it is more powerful to do it individually and see then where do you align and where do you match up in terms of priority so that you’re starting with that conversation. Then, it’s impossible to change everything all at once. I would recommend that the group picks one thing to focus on. This is well-being, and implementing many of these things is like implementing all of the other bundles and things that we’ve implemented in critical care. It’s really hard to implement all of the steps of the ICU Liberation work at the same time. So you focus on that low-hanging fruit, you focus on the easier things, and then you go from there.
Some of the things, mattering is just this idea that the work that I do is making a difference. That, and being part of a community is, I’m part of a community, that’s as simple as introducing each other using first names. I think globally, one of the things that we have to figure out in critical care is that we are interdisciplinary and we are a team. But it’s not like when I started as a critical care nurse and the team was the same people every single day. We work with a different team every single day. Our providers change weekly. Sometimes the nurse and respiratory therapists are changing daily, right? There’s a new concept in the literature, that is teaming. The idea of teaming is it’s different people every day, but you can still work as a team.
A really good example in critical care is a code. It’s a different code team that responds every single time. But everyone knows that you need somebody to do CPR and somebody to do meds and somebody to lead the code and somebody to do the airway and somebody to run the code cart. You have the roles and you teach to those roles and you make sure that people understand. We need to think about that same thing. We need to make sure that all the members of our team understand the role and the expectation, and that would go a long way toward helping with well-being because some of the conflict comes from having different expectations of the different roles than is really realistic.
Dr. Enfield: Thanks for that really great reminder that we really are better together, which I know has been the theme of the SCCM 2023 Congress, and I want to thank you for this work. This is amazing work. I got to download the Well-Being Toolkit about a week ago and was just really impressed with the thought that had gone into building that. For all the listeners out there, if you have not downloaded the Well-Being Toolkit, I would strongly encourage you to do that. Take some time, work with your groups, and really think about what we can do differently as we move into the future, because we all need each other if the ICU is going to continue to move forward, and I think there’s a lot of strain in our system. Is there any one final thought you’d like to leave the listeners with?
Ms. Valcin: I think the one final thought that I would like to leave the listeners with is actually a quote from Helen Keller that I use a lot and it’s the power of one. What Helen said was, I’m one, but I’m not going to do nothing because I’m just one. By moving forward and doing something, I can begin to make the change in the world.
Dr. Enfield: With those wonderful words, this will conclude another edition of the Society Critical Care Medicine Podcast. For the Society of Critical Care Medicine, I’m your host, Kyle Enfield. Thank you.
Kyle B. Enfield, MD, FSHEA, FCCM, is an associate professor of medicine in the Division of Pulmonary and Critical Care at the University of Virginia. He received his undergraduate degree and joint medical and master’s degree from the University of Oklahoma.
This podcast was recorded during the Society of Critical Care Medicine’s 2023 Critical Care Congress. Access essential education online through Congress Digital. More than 120 sessions are available on an easy-to-use platform. Continuing education credit is also available. Some SCCM members receive complimentary access to Congress Digital. To learn more, visit sccm.org/congressdigital.
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