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Burnout Syndrome in the ICU
By James E. McFeely MD, Medical Director Critical Care Units, Alta Bates Summit Medical Center, Berkeley, CA, is Associate Editor for Critical Care Alert.
Dr. McFeely reports no financial relationship to this field of study.
Burnout syndrome (BOS) is a condition in which professionals lose concern and emotional feeling for the people they work with, and come to treat them in a detached or even dehumanizing manner. Burnout in the context of the Intensive Care Unit (ICU) is a psychological response to chronic interpersonal stress on the job. We are all aware of colleagues who appear burned out. The syndrome is so pervasive in the ICU that it almost has become a part of the background noise. In the last few years, several studies have documented the severity and extent of burnout in both intensivists and critical care nursing staff.
Burnout syndrome is described as an inability to cope with emotional stress at work or as an excessive use of energy and resources leading to feelings of failure and exhaustion. While objective study of BOS takes intensivists into less familiar disciplines such as psychology and anthropology, research in these fields shows the vast extent of burnout in our work environment and points to institutional factors as those most associated with the phenomenon.
How Can Burnout Be Detected and Quantitated?
A simple measurement tool called the Maslach Burnout Inventory (MBI) has been developed and well validated for detecting and measuring the severity of BOS. The scale evaluates three domains: emotional exhaustion, depersonalization (negative or cynical attitudes towards patients), and loss of feeling of personal accomplishment at the work site. This tool has been applied in several different studies, all of which point to an epidemic of burnout in the ICU.1-3
How Common Is It, And Who is Most Likely To Get It?
Embriaco and colleagues sent the MBI questionnaire to directors of 318 ICUs in France in early 2004.1 Practicing physicians returned 978 surveys. As measured by the MBI, a high level of burnout was identified in 47% of the responding intensivists, while a moderate level of burnout was identified in a further 30%. Depersonalization was observed in 37% of the respondents, with a high level of emotional exhaustion in 19% and a low level of personal accomplishment in a further 39%. In all, 40% of the respondents indicated that they wanted to leave their current jobs. Of those intensivists exhibiting high levels of burnout on the MBI scale, 51% indicated they wanted to change careers.
In univariate analysis of the same data, certain groups showed higher levels of burnout than others. These included female intensivists; younger intensivists and those who were unmarried or childless; and physicians reporting conflicts with nurses, colleagues, or patient families during the seven days prior to taking the survey (in contrast, good quality relationships with chief nurses and nursing staff were associated with a lower score on the survey). Higher degrees of burnout were also associated with organizational factors such as increased workload (working hours per week, number of night shifts per month, compensation for overtime and recent vacations). Interestingly, the severity of illness of patients (as quantified using the SAPS II score) and mortality rates did not correlate with the rate of burnout.
A similar study was performed using the same MBI instrument to measure burnout in critical care nurses in France.2 Of the 2,392 respondents, 33% of these nurses had severe BOS as measured by the MBI. In multivariate analysis of this data, four groups of characteristics were associated with severe burnout: personal characteristics such as younger age; organizational factors such as the ability to control one's schedule and participate in clinical research; quality of working relationships, including those with patients, head nurses and physicians; and end-of-life variables such as caring for a dying patient or decision-making regarding life-sustaining treatments within the week prior to taking the inventory.
A separate study performed across the European Union found that burnout tended to cluster in ICUs.4 Multilevel analysis showed that burnout complaints among colleagues made a statistically significant and unique contribution in predicting variance in burnout rates between units. This suggests burnout may be communicated within a unit from one nurse to another—exemplifying the phenomenon of "emotional contagion" substantiated by a wide-range of disciplines.
Burnout, Post-traumatic Stress Disorder and Moral Distress
Critical care nurses were also recently given survey instruments to determine the prevalence of symptoms of post-traumatic stress disorder (PTSD), anxiety, and depression.5 Of 230 ICU nurses who completed the surveys, 21% recalled having nightmares and 17% had severe anxiety and panic related to experiences working in the ICU. The most frequent symptoms among these nurses were sleep problems, irritability, agitation, anger, and muscle tension. These ICU nurses with positive symptoms consistent with PTSD were more likely to work evening or night shifts and were less likely to have taken on the role of charge nurse. While PTSD may be the upper end of a stress response continuum rather than a distinct pathologic entity, the majority of these nurses would meet diagnostic criteria for sub-threshold PTSD, a rate of subclinical PTSD similar to those found in female Vietnam veterans.
The development of moral distress, which results when a person perceives that the right course of action cannot be implemented because of outside constraints, has also been studied. In a survey of 60 critical care nurses, moral distress accounted for 10% of the variance of the emotional exhaustion subscale of the MBI.6
What Can Be Done about Burnout Syndrome?
The first step in attempting to control work stress is for an organization to understand that work stress is an organization-level problem, not an individual employee's problem, and that prevention and treatment of burnout requires an integrated response from the institution as well as the individuals working in the ICU.7-10 Where work stress exists, hospital administrators must recognize it and provide resources in order to mitigate it. Helpful measures include more flexible shift scheduling (which is associated with decreased frequency of burnout among nurses); training in communication between hospital staff and patient families as well as between doctors and nurses; and mutual support and debriefing (perhaps with the assistance of an outside party) after a difficult case or acute crisis.
Of course, some variables associated with increased rates of burnout are difficult to control, such as work flow (random rapid increases in census, lack of staff) and unreasonable or difficult families. But even in those situations, contingency plans can be developed. Flexible staffing and a coordinated response to triage between the physicians and nursing administration can help with workflow problems. Social workers, case managers, ethics committees and the availability of a palliative care service can occasionally help in dealing with patient families.
Role of The Medical Director and Nurse Manager
Medical directors and nurse managers have a particularly important role in countering the contagion of burnout. They can do this by creating an overall supportive environment in the unit, with an emphasis on peer group support and positive socialization within the unit. They must discourage bullying or negative comments and promote positive feedback to colleagues when they perform well, as well as make staff feel that their leaders empathize with the tasks they are trying to accomplish. In general, medical directors and nurse managers must attempt, and staff must perceive them making every possible attempt, to minimize stress in what is a physically, cognitively and emotionally demanding work environment.
For readers interested in measuring the amount of burnout in their own units, the Maslach Burnout Inventory can be purchased at this website: http://www.cpp-db.com