Stressful intensive care unit medical crises: How individual responses impact on team performance* Dominique Piquette, MEd, MD, MSc, FRCPC; Scott Reeves, PhD; Vicki R. LeBlanc, PhD T he intensive care unit (ICU) has been described as a stress- ful working environment by healthcare professionals (1). Many studies have reported an extensive number of acute and chronic stressors encountered by nurses and physicians in this setting, such as noise (1), emergen- cies (1, 2), end-of-life care (1–3), interac- tions with families (1, 2), equipment failure (1), workload (1, 2, 4), and relationship with work colleagues (1– 4). However, the specific manner in which these stressors may affect performance of healthcare professionals, care delivery, and clinical outcomes of patients are still largely un- known. Studies completed in other stressful environments, such as the aviation and the military fields, have shown an associ- ation among high level of stress, team- work failure, and impaired performance (5). Accordingly, the report on medical error produced by the Institute of Medi- cine in 1999 recommended targeting these human factors to improve the training of healthcare professionals work- ing in acute settings (6). In the ICU, med- ical errors have been shown to be highly prevalent yet potentially avoidable (7–9). This setting could potentially benefit from interventions targeting stress. How- ever, a better understanding of the cir- cumstances in which certain stressors lead to impaired performance in the ICU is needed to design such interventions. Staff well-being is another major con- cern for stakeholders involved with acute care environments. Recently, a growing number of studies have reported a high prevalence of psychological symptoms among ICU healthcare professionals (2– 4). Symptoms of burnout and acute post- traumatic syndrome were identified more frequently among healthcare profession- als than in other care settings. Stress has been linked to negative emotions such as anger and anxiety (10, 11) and could con- stitute a target to improve ICU staff well- being. However, stress responses are likely to vary in time, between individuals, and according to the context. These variations need to be better understood before design- ing any specific intervention. We undertook a qualitative study that aimed to determine the perceived effects of stress on performance by healthcare professionals during ICU medical crises (i.e., events requiring the immediate intervention of multiple ICU team members to respond to a pa- tient’s acute instability). Our goal was to answer the three following ques- tions: 1) What are the stressors encoun- tered by healthcare professionals dur- ing ICU medical crises?; 2) Under which circumstances are these stressors most likely to affect individual or team per- formance?; 3) How do individual and *See also p. 1494. From the Department of Critical Care, Sunnybrook Health Sciences Centre (DP), Toronto, Ontario, Canada; Wilson Centre (DP, SR, VRL), University Health Net- work, Toronto, Ontario, Canada; Li Ka Shing Knowl- edge Institute (SR) and Centre for Faculty Development (SR), St Michael’s Hospital, Toronto, Ontario, Canada; Department of Psychiatry (SR) and Department of Medicine (VRL), University of Toronto, Toronto, Ontario, Canada; Ornge Transport Medicine (VRL), Toronto, On- tario, Canada. This work was supported by departmental funding. The authors have not disclosed any potential con- flicts of interest. For information regarding this article, E-mail: dominique.piquette@sunnybrook.ca Copyright © 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: 10.1097/CCM.0b013e31819c1496 Background: Intensive care units (ICUs) are recognized as stressful environments. However, the conditions in which stres- sors may affect health professionals’ performance and well-being and the conditions that potentially lead to impaired performance and staff psychological distress are not well understood. Objectives: The purpose of this study was to determine health- care professionals’ perceptions regarding the factors that lead to stress responses and performance impairments during ICU med- ical crises. Design: A qualitative study in a university-affiliated ICU in Canada. Methodology: We conducted 32 individual semistructured in- terviews of ICU nurses, staff physicians, residents, and respira- tory therapists in a university-affiliated hospital. The transcripts of the audiotaped interviews were analyzed using an inductive thematic methodology. Results: Increased workload, high stakes, and heavy weight of responsibility were recognized as common stressors during ICU crises. However, a high level of individual and team resources available to face such demands was also reported. When the patient’s condition was changing or deteriorating unpredictably or when the expected resources were unavailable, crises were assessed by some team members as threatening, leading to individual distress. Once manifested, this emotional distress was strongly contagious to other team members. The ensuing collec- tive anxiety was perceived as disruptive for teamwork and dele- terious for individual and collective performance. Conclusions: Individual distress reactions to ICU crises oc- curred in the presence of unexpectedly high demands unmatched by appropriate resources and were contagious among other team members. Given the high uncertainty surrounding many ICU med- ical crises, strategies aimed at preventing distress contagion among ICU health professionals may improve team performance and individual well-being. (Crit Care Med 2009; 37:1251–1255) KEY WORDS: stress; team interactions; medical crises; interpro- fessional collaboration 1251 Crit Care Med 2009 Vol. 37, No. 4