“How was work today?.” It is an innocent enough question—but not an easy one to answer when you work in intensive care. Aside from obvious issues relating to confidentiality, so much of what we witness, working in these settings, is unspeakable, shocking, and sad. And when the unit is one that treats children, it feels socially unacceptable, outside the hospital, to even hint at what we are dealing with daily. In the pandemic, there was an even greater gulf between what people understood about what was going on in hospitals and the reality, prompting a number of studies on the psychological repercussions of this work for staff.

One such study by Lima-Setta et al (1) appears in this edition of Pediatric Critical Care Medicine. The authors report the findings of an online survey of n = 1,084 multidisciplinary healthcare professionals across 29 PICUs in Brazil, working during the first wave of the global COVID-19 pandemic in 2020. They used standardized self-report measures of anxiety, depression, burnout, and post-traumatic stress disorder (PTSD) and found that those with previous mental health problems scored higher than others and that younger members of staff reported more burnout. Also, those working in public healthcare settings were at increased risk of burnout and PTSD. They observe that the levels of distress found were similar to those reported by adult critical care workers in the same country, illustrating that the lower prevalence of serious disease in pediatric patients was not associated with lower rates of distress in pediatric staff, since they were called upon to assist their adult colleagues in this unprecedented situation and so did not have reduced exposure to the terrible consequences of this disease.

The redeployment of pediatric staff in this situation has been found to be associated with increased risk of psychological distress (2), not only because of the disruption this caused to normal working on top of all the other stressors experienced by their adult ICU counterparts (limited staff testing; inadequate personal protective equipment; unknown disease; high death rate), but also specifically because many nurses lacked generic adult training (3).

Perhaps the most interesting and most novel finding in the study by Lima-Setta et al (1); however, which has implications beyond the pandemic, was that 80% of staff claimed they were “satisfied” or “very satisfied” at work despite their elevated psychological distress. The authors explain that this sample demonstrated a particular profile of burnout symptoms, namely the “overextended” (4) profile. This refers to a constellation of symptoms in which high levels of exhaustion are reported, but also high levels of achievement, in the absence of “depersonalization” often regarded as the hallmark of burnout, indicating that their empathy for patients has remained intact. The authors comment thoughtfully in the Discussion about the importance of altruism and of staff acknowledgment of the value of this work, which appeared to sustain them even when they were facing the very real fear of catching or spreading this highly virulent disease.

A number of lessons have been learned in relation to the impact of the pandemic on staff wellbeing. While it is clear that staff “overextended” themselves in a crisis and that there were costs to this for them personally, this did not prevent them from finding meaning in what they did and appreciating working in supportive teams. Two recent qualitative studies on intensive care staff’s experience of the pandemic have also drawn attention to positive aspects of the pandemic experience, which were not apparent in the early quantitative studies of staff wellbeing in this situation, as these focused understandably on quantifying distress.

In an analysis of free-text comments from n = 269 adult and pediatric intensive care staff working in Ireland in the first wave of the pandemic, Feeley et al (5) comment on the importance to this group of their strong professional identity and of how much they valued supportive interactions with colleagues (although they voiced mixed reactions to being referred to as “heroes” by the public).

Another qualitative study of n = 339 critical care nurses after the second wave in the United Kingdom also describes positive factors (6). Nurses reported feeling they were making a real difference in relation to this work and valued both the camaraderie inherent in good teamwork and the support they received from senior nurses. The authors sum up their findings as demonstrating the “costs and joys of care” while appreciating the very real impact of the shortage of resources on nurses’ ability to meet their patients’ needs at the time.

The study by Lima-Setta et al (1) has a number of strengths including its sample size; its focus on multidisciplinary PICU staff; the fact that it was multisite and the comprehensive set of measures used to quantify the nature of the work-related distress being reported. The response rate was, at 72%, also impressive for a survey of this type.

Limitations include the fact that the study was cross-sectional, so causality could not be inferred; junior nurse support workers were under-represented, and there was no direct comparison group, although comparisons are made with other studies in this literature. Also, the definition of “burnout” used was over-inclusive in that it only required any one of the three sets of symptoms measured to be in the high range for someone to be classified as positive for burnout. Research has demonstrated that depersonalization is the most serious aspect of burnout in terms of its impact on functioning (4) and that exhaustion, on its own, does not constitute burnout, as evidenced by its quick reversal when staff are provided with more rest (7). Finally, although the PTSD scale used cannot be regarded as diagnostic, the findings did suggest that these symptoms were elevated, as they have been found to be in other large samples of critical care workers in relation to working during the pandemic (8).

It may be helpful to return to the “overextended” subtype of burnout if we are to learn something from the findings of Lima-Setta et al (1) that might apply to work life after the pandemic, particularly given research evidence of the extent of the preexisting strain on PICU staff (9). Admittedly, the pandemic was an extreme situation in relation to the demands placed on staff, but in intensive care, the job is literally about life and death every day, and there is always a compelling reason to stay late, to overwork. How can we apply ourselves to this noble calling without either becoming too detached in our efforts to protect ourselves from others’ suffering or over-exhausted as we endeavor to maintain empathy for the families’ predicaments (10)?

A number of new insights related to this dilemma are provided in another recent study, which used statistical learning algorithms to examine risk and protective factors associated with symptoms of PTSD in n = 1,017 physicians’, after the second wave of COVID-19 in the United States (8). The authors found that around 30% of their sample exhibited probable or borderline PTSD and that certain PTSD symptoms discriminated between those who were frontline in the pandemic and those who did not treat COVID patients directly. Risk factors for higher PTSD scores included coexisting depression and burnout but also self-blame, possibly indicating a degree of moral injury. They also looked at protective variables and found support from within the organization, as well as from friends and family, appeared protective and that training in psychosocial care was independently associated with lower rates of PTSD.

Emotional processing of traumatic events is necessary in order to avoid long-term psychological sequelae, but this requires being able to describe and express feelings safely to others who understand the context (11). Writing about the complicated way our personal and professional lives collide is another way to process these experiences and reflect on them either privately or by sharing them with colleagues in journals such as this one (12,13). In doing so, it is possible also to acknowledge the way that our lives can be enhanced by this work, as well as challenged by it (14,15). We need to be able to answer honestly “How was work today?” and to acknowledge that, as Lima-Setta et al (1) report, even in the darkest of times, it is possible to find meaning in what we do.

1. Lima-Setta F, de Moraes CL, Silami PHNC, et al.; Brazilian Research Network in Pediatric Intensive Care (BRnet-PIC): Mental Health and Emotional Disorders During the COVID-19 Pandemics: Prevalence and Extent in PICU Staff. Pediatr Crit Care Med 2023; 24:277–288 2. Ffrench-O’Carroll R, Feeley T, Tan MH, et al.: Psychological impact of COVID-19 on staff working in paediatric and adult critical care. Br J Anaesth 2021; 126:e39–e41 3. Mohta S, Alexander J, Colville G: The experience of paediatric staff caring for adults with Covid-19. Arch Dis Child 2021; 106:A344 4. Leiter MP, Maslach C: Latent burnout profiles: A new approach to understanding the burnout experience. Burn Res 2016; 3:89–100 5. Feeley T, Ffrench-O’Carroll R, Tan MH, et al.: A model for occupational stress amongst paediatric and adult critical care staff during COVID-19 pandemic. Int Arch Occup Environ Health 2021; 94:1721–1737 6. Stayt LC, Bench S, Credland N, et al.: Learning from COVID-19: Cross-sectional e-survey of critical care nurses’ satisfaction and experiences of their role in the pandemic response across the United Kingdom. Nurs Crit Care 2022 Oct 7. [online ahead of print] 7. Mikkelsen ME, Anderson BJ, Bellini L, et al.: Burnout, and fulfillment, in the profession of critical care medicine. Am J Respir Crit Care Med 2019; 200:931–933 8. Mukherjee S, Rintamaki L, Shucard JL, et al.: A statistical learning approach to evaluate factors associated with post-traumatic stress symptoms in physicians: Insights from the COVID-19 pandemic. IEEE Access 2022; 10:114434–114454 9. Colville G: Paediatric intensive care nurses report higher empathy but also higher burnout than other health professionals. Evid Based Nurs 2018; 21:25 10. Jones GAL, Colville GA, Ramnarayan P, et al.: The psychological impact of working in paediatric critical care. A UK-wide prevalence study. Arch Dis Child 2020; 105:470–475 11. Disch J: Rethinking mentoring. Crit Care Med 2018; 46:437–441 12. Mills M: PCCM narrative: Waves. Pediatr Crit Care Med 2022; 23:936–937 13. Rissman L: Protecting it. Pediatr Crit Care Med 2020; 21:e922–e923 14. Schwingshakl A: The fallacy of chasing after work-life balance. Front Pediatr 2014; 31:26 15. October TW: Work-life balance is an illusion: Replace guilt with acceptance. Front Pediatr 2015; 17:76