ICU Management & Practice, Volume 21 - Issue 2, 2021

ICU is a Team Sport

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The importance of creating a psychologically safe workplace and the need for a fundamental shift in workforce culture to foster compassionate leadership and collaborative approaches to delivering safe, supported care.

I write this almost one year to the day after the UK announced its first coronavirus pandemic lockdown. The next few months were full of confusion, uncertainty, and fear. The world was facing a threat it didn’t recognise, didn’t understand, and couldn’t stop. People were arriving at hospitals with unusual symptoms and there was a very real risk that frontline healthcare staff would be infected by the very people they were trying to save. The outlook was bleak.


And for several months it was bleak. Daily reports of national deaths were increasing, prediction models weren’t optimistic, health services in every country were treating more patients than their hospitals were ever meant to admit, and there was no signal that the virus was subsiding. But through this, through all the confusion and through all the fear, the international intensive care community came together. Online conference calls became a regular feature as teams from all over the world shared their experiences of COVID-19. Through these shared experiences we learned. We learned how to recognise patients most at risk of dying. We learned how to treat patients who were younger and sicker than we were used to seeing in the ICU. We learned about protective clothing. We learned how to set up emergency critical care units in a very short time. We learned how to save lives. But most of all we learned to cope.


A year on, the world is still reeling and it may be that things will never be entirely the same again. But some things for sure are more certain. Tens of thousands of patients have taken part in global research projects to help us understand what we are dealing with. We have evidence-based treatments that work. It is equally important that we have evidence to show which treatments don’t work. After what is perhaps the most successful scientific discovery and development programme the world has ever seen, we have several vaccines in circulation. And, despite the mutations in the virus, and the restrictions that are still in place in many countries, we have hope. We have hope because we were able to move quickly and deliver what the world needed. We have hope because we understood we were a community. We have hope because we shared.


Lessons learned through sharing experiences of the pandemic are not limited to medical care. More people than ever are finding they are struggling to sleep. Poor sleep is linked to a number of health problems including high blood pressure, low immunity, and poor mental health. Everyone should be looking for ways to maximise their sleep, aiming for 7-8 hours every night. It is perfectly normal for everyone to have a bad night’s sleep every now and again. This is normal, and not something that people need to add to their daily worries. But some people are finding their sleep is disrupted more often, especially after the last year.


Sleep for shift-workers has always been problematic and tips for managing fatigue include short naps overnight to maintain cognitive function (drink your coffee immediately before napping for 15-20 minutes as the caffeine will just be starting to take effect on waking), wearing sunglasses for the trip home after a nightshift to reduce the effects of morning light, and designing rotas that work with natural circadian rhythms.


The recent increase in sleep problems has led to the identification of Coronasomnia or COVID-somnia as the pandemic has been responsible for much of the change in sleep patterns and increased demand for sleep medications. Initially, for those in healthcare at least, this insomnia was fuelled by worries associated with the pandemic. Healthcare workers the world over were waking up in the middle of the night wondering how their patients from yesterday were doing, and how many new patients would come through the doors tomorrow. As treatments for patients admitted to hospital with COVID-19 have been identified, some of these uncertainties have been resolved but outside of the hospital, healthcare workers are still affected by all the same things that worry everyone else. Lockdown restrictions everywhere have put a strain on the economy. Job security isn’t perhaps what it was. No activity is ever 100% safe but over the last year so much we have previously taken for granted now comes with an unknown risk of severe illness, or even death, from a danger we cannot control. There is a real risk of infection when mixing with others, and even with good quality PPE (which hasn’t always been available), many healthcare workers have needed to use public transport to and from work where mixing with other people is unavoidable. Infection control and health protection measures mean that for many, their usual stress-relieving activities have been restricted, or even taken away altogether if they cannot be done alone. Holidays have been limited. Nothing seems normal. With all of this comes a collapse of the daily routine and an increase in restlessness. It’s no wonder our anxieties make themselves heard in the dark when we are alone with nothing but our thoughts to keep us company.


There is no silver bullet solution to chronic sleep problems. Medication is available but is really only intended to be used for short-term improvements. Understanding sleep in a more general sense is key to longer-term success and it is perhaps time to think about sleep in the same way that we do about exercise. In many ways sleep is exercise. Whilst we sleep our brains refresh themselves and revisit events to create memories. Improving sleep for patients admitted to ICU is part of the movement to humanise the ICU and, as we learn more about the healing role of sleep, we can focus more on sleep as a vital part of good health. As we encourage our patients to keep to a routine, to keep moving and to work with the natural rhythms of the day to maintain orientation we should do the same. Natural daylight is key to setting the body clock. We should all aim to spend some time every day outside, ideally in the morning. We should find the energy for exercise. It is much easier to fall asleep when we are physically tired. Good sleep hygiene practices also limit electronic screen use in the hours leading up to bedtime. Most phone/tablet screens emit a blue-tone light similar to the frequencies of natural daylight that trigger the brain to ‘wake up’. The natural circadian rhythm expects a dulling of colour towards the red/orange end of the spectrum at the end of the day. Many operating systems can mimic this with ‘night-time’ settings but there are plenty of other good reasons why you shouldn’t be working or ‘doom-scrolling’ just before bed.


The emotional burden that surrounds intensive care isn’t something that only comes along with a pandemic. Even in the quiet times we need to remember how to care for ourselves, our friends, and our families. Even when life outside the hospital finds some kind of new normal, things may never return to normal for those who have been left with long-term effects. Recent events have highlighted just how important it is to understand mental wellbeing as well as physical health. This includes having a strong support network and a psychologically safe workplace.


A psychologically safe workplace needs to consider the system as a whole. It is not enough to focus on training the individual to manage their own wellbeing in isolation of other factors. Look after your colleagues. Ask if they are okay. The patient is not always in the bed. As we look ahead to what might be a period of respite from the relentless intensity of COVID-19, we need to take the time to reflect. As health systems around the world rebuild, now is the time to rebuild better. We have the opportunity to celebrate the incredible achievements and make permanent changes that will improve the way we care for our patients and for ourselves. There needs to be a fundamental shift in workforce culture to foster compassionate leadership and collaborative approaches to delivering safe, supported care to those who need it.


At the end of the summer last year coronavirus admissions to hospital and ICU were dropping and everyone was exhausted. The thought of “doing it again” was terrifying. As we head into summer again it is very clear that we have “done it again”. We also know we may need to keep “doing this again” for some time. But it will be okay. It will be hard. There will always be those patients who stay with us forever but with the right support we can cope. We can face this together. We are a team.


Conflict of Interest

None. 


Key Points

  • The world is still reeling from COVID-19, and it may be that things will never be entirely the same again.
  • However, some things are certain. Thousands of patients have taken part in global research projects; there is evidence of treatments that work and those that don’t; there are several vaccines in circulation, and most of all, there is hope.
  • Recent events have highlighted just how important it is to understand mental wellbeing as well as physical health.
  • The recent increase in sleep problems has led to the identification of Coronasomnia or COVID-somnia as the pandemic has changed sleep patterns and has increased demand for sleep medications.
  • There needs to be a fundamental shift in workforce culture to foster compassionate leadership and collaborative approaches to delivering safe, supported care to those who need it.

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