Improving resilience in anaesthesia and intensive care medicine – learning lessons from the military

Resilience in the context of anaesthesia and intensive care medicine is the ability to manage the breadth, depth, intensity and chronicity of the demands of the work. The concept of resilience is often misunderstood: it is a dynamic, contextual process that goes beyond the narrow conceptions of individual ‘toughness’ that it can be reduced to. Resilience is important for those working in anaesthesia and intensive care medicine, and indeed staff throughout healthcare, as it is inevitable that difficult cases and situations will be encountered during our working lives. In addition, the way in which we respond to these events is critical to our own welfare and competence at work. This article is about accepting that our working lives are difficult, that this is a big part of the attraction of our work and that it is wise to look at ways in which both team and personal resilience can be improved. Trauma risk management uses the following definitions: a traumatic event is an incident occurring outside the practitioner's usual experience that causes physical, psychological or emotional harm; a ‘trauma stress reaction’ is a normal response to an abnormal incident (traumatic event) and is relatively common. Post-traumatic stress disorder is much rarer than a trauma stress reaction and can develop if a patient with a trauma stress reaction does not receive timely help and support. There is a wide spectrum of responses to one given event and it can be very difficult to predict who will experience a severe reaction. Trained ‘TRiM practitioners’ are embedded within all military units and have the following roles: they intervene early following a traumatic event, aiming to keep staff working in their usual environment; they look out for their team, normalise symptoms and reassure staff that they are likely to make a full recovery with time and self-care; and they screen staff on three occasions following a traumatic event – at 3 days, 30 days and 3 months – and calculate a ‘TRiM risk assessment score’. In most staff, a serial drop in this assessment score is seen at each assessment point, but staff who have a score which rises between 3 and 30 days are most at risk of ongoing mental health issues and may benefit from additional support from a psychologist 1, 3. Trauma risk management has been successfully used in healthcare 3 and was introduced formally in Bath hospital following their ICU fire 5-7; TRiM principles were used very successfully there by clinical psychologists and counsellors to care for staff involved in the fire 6, and a formal TRiM system was subsequently put in place. Staff awareness and education about acute trauma–stress reactions was promoted, a team of TRiM practitioners trained and a protocol established. Trauma risk management (MEDTRiM) was independently introduced in Wales in 2014 3: this is a course run by a trained TRiM practitioner and clinician which teaches the skill of dealing with a potentially traumatic event and a variety of practical well-being skills 3. Other UK hospitals have since set up TRiM systems, followed by pre-hospital care teams, paramedics, fire services and the police force. Trauma risk management is low cost, may even save an organisation money by keeping staff at work and avoiding sick leave and early retirement 3 and may reduce the stigma of mental health issues 1. Team resilience can be improved by national 10-18, Trust 1-3 and departmental 19, 20 strategies (Table 1). National strategies include the #fightfatigue campaign launched in 2018 10-12 following the tragic death of Dr R. Patel, an anaesthetic registrar who crashed his car while driving home after a night shift 13. Trust and departmental strategies include even simple actions such as knowing the first names of your team, thanking them when appropriate and providing refreshments following ward rounds. ‘Going home checklist’ 16 Mentors for consultants as well as trainees Academic ‘families’ Departmental social events Recognising staff who have gone above and beyond, for example, GREAT-IX 20 Many strategies exist for improving personal resilience and can be summarised by the ‘three C's of resilience’: control what you can, cope with what you cannot and concentrate on what is important 3. These are described by ‘Stacey's Baker's Dozen’ (see also Supporting Information, Appendix S1). Key themes are the importance of sleep (‘the most powerful performance enhancer known to man’), regular food and drink, prioritising exercise and the concept of active daily ‘self-care’ 3. Many of these resilience-improving strategies are used by elite athletes, and it is possible that, in addition to improving our resilience, they may also improve our day-to-day performance at work (and at home) 3. In summary, resilience is important for staff working in anaesthesia and intensive care medicine where difficult cases and situations are inevitable. National, Trust and departmental strategies to improve team resilience are likely to improve patient safety, and, if supplemented with strategies to improve personal resilience, may also improve personal performance. The department that FK works in has received equipment for evaluation, research and training at cost price, for free or on loan. MS runs a MEDTRiM course with Professor A. McCann. No other external funding or competing interests declared. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. 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