By Linh H. Vu, MD, and Alexander S. Niven, MD

Dr. Vu is Pulmonary and Critical Care Medicine Fellow, Mayo Clinic, Rochester, MN. Dr. Niven is Senior Associate Consultant, Division of Pulmonary/Critical Care Medicine, Mayo Clinic, Rochester, MN.

The burnout epidemic has plagued the medical profession for decades, with an escalating prevalence most recently fueled by the COVID-19 pandemic.1,2 The challenges that hospitals have faced with high patient volumes, critical staff and supply shortages, and their impact on workforce burnout now are well recognized. The pandemic has highlighted that the cost of burnout is not isolated to the individual providers, but also affects the quality of patient care, healthcare systems, and society at large.

The critical care workforce has been on the front line of the COVID-19 pandemic, and initial reports suggesting rising burnout rates in this community likely underestimate its scope and long-term impact.1 This article summarizes our current understanding of how burnout is affecting critical care teams, including its influence on healthcare provider morale, well-being, and performance. We also will examine potential approaches to prevent and address burnout not only on an individual level, but more importantly, within medical teams, organizations, and society as a whole.

Definition and Background

Burnout is a syndrome of extreme exhaustion, depersonalization or detachment from work, and skepticism regarding personal accomplishment.2 Exhaustion happens when what is demanded exceeds a provider’s adaptive capacity, with a focus on the emotional repercussions that follow. The COVID-19 pandemic has amplified the demand for critical care not only in terms of volume of patients per provider, number of shifts, and work hours, but also in the emotional turmoil associated with increased morbidity, accumulating mortality, and constant uncertainty from this disease. This quickly can lead to emotional exhaustion, compassion fatigue, detachment, decreasing ability to empathize or engage, and apathy toward patient care. Callousness and treating patients as objects are associated with the most severe forms of depersonalization. A poor sense of personal accomplishment can manifest in a variety of ways, including feelings of helplessness, uselessness, decreased productivity, or a more widespread perception that patient care and professional accomplishments are worthless.

Other work-related conditions that often accompany burnout in healthcare include second victim syndrome and moral distress or injury. Stressful or traumatic work-related events, such as the loss of a patient, unanticipated outcomes, uncertainty, violent patient encounters, near-miss clinical incidents, or multiple difficult events over a short period, can put providers at risk of becoming a “second victim.” The emotional trauma that they experience from the event can include a sense of personal responsibility and failure, rumination and reliving the event, and second-guessing their knowledge and skills. Healthcare providers’ intrinsic values of altruism, compassion, and a desire to help often go along with a strong sense of ethics. When internal (e.g., professional self-doubt, lack of confidence) or external (e.g., scarce resources) barriers prevent the provider from taking the ethically appropriate course of action during clinical activities, moral distress and injury can occur. These situations can affect professional work and personal health, and, if left unaddressed, can lead to mental health issues including post-traumatic stress disorder (PTSD).

Resiliency is an important attribute that can help an individual recover or “bounce back” from these challenging situations, and the term grit often is used to describe one’s ability to persevere and “rise above” adversity.3 Initial efforts to combat burnout often focus on fostering these individual characteristics. Although this is important, experts emphasize that individual strategies alone without team- and system-level support are unlikely to combat healthcare worker burnout and its consequences effectively.4

Scope of the Problem

Burnout is a mounting global healthcare crisis, especially for members of frontline medical teams.5,6 Prior to the COVID-19 pandemic, a systematic review of critical care physicians reported an overall burnout rate ranging from 6% to 47%, with a U.S. prevalence in the three burnout domains of exhaustion, depersonalization, and reduced personal accomplishment of 61%, 44%, and 51%, respectively.7 A Mental Health America survey of 1,119 healthcare workers in 2020 found that 93% reported feeling stress and 76% reported burnout.8 From 2020 to 2021, critical care physicians have gone from 10th to first place in self-reported burnout based on a national survey.1 Other members of the interprofessional intensive care unit (ICU) team also have been significantly affected. ICU nurses, for example, reported an increase in burnout rates from 58% to 72%.9

In addition to its negative effects on mental health and physical well-being, burnout can affect personal and professional relationships, work performance, teamwork, quality of patient care, and healthcare delivery scope and effectiveness. During the pandemic, physicians have reported an increase in unhealthy habits to cope with their symptoms of burnout, including isolating themselves from others, poor dietary choices, and substance use (alcohol, prescription drugs, smoking).1 Burnout is associated with poor sleep quality, sleep disorders, mood and libido disturbances, memory impairment, anxiety, depression, and suicidal ideation.10-12 From a professional perspective, burnout is associated with lower patient satisfaction, increased safety concerns, and an overall lower quality of care.13 In a 2021 Medscape physician survey, 10% of respondents felt that burnout was severe enough to consider leaving medicine despite their significant time and financial investment in training.1 The resulting decreases in productivity and access and increased workforce turnover are estimated to cost healthcare systems between $3,700 to $11,000 per physician and approximately $4.6 billion per year in the United States.14

Driving Factors of Burnout

There are many interwoven factors that drive burnout. In general, they can be thought of in domains affecting the life and work of critical care providers, including personal, workplace, and organizational factors. Specific challenges identified in association with the COVID-19 pandemic are listed in Table 1.15

Table 1: Healthcare Worker Challenges Associated with the COVID-19 Pandemic and Potential Healthcare System Solutions

Principle

Challenges

Solutions

Prepare Me

  • Insufficient planning, communication
  • Dedicated training for frontline, additional staff
  • Agile leadership, staff quality improvement and empowerment

Support Me

  • Negative work environment
  • Longer, more intense shifts
  • Appropriate staffing, team and system redesign
  • Individual, team behavioral support programs
  • Escalation process for clinical, ethical concerns

Protect Me

  • Threat of occupational exposure
  • Sufficient supplies, protective equipment
  • Lean processes, safeguards

Care for Me

  • Risk of illness to self, family
  • Organizational, financial support for sick leave, family care plans, medical expenses

Honor Me

  • Disruption of work-life balance
  • Neglect of personal, family needs
  • Scheduling to allow for personal recovery
  • Support for caregiver responsibilities
  • Recognition, gratitude by leaders, peers

Younger age has been identified consistently as a strong risk factor for burnout.10,16,17 At-risk individuals often have limited social support, are single, are living without a family, and have lower income.18 The social disruption created by the COVID-19 pandemic has increased the risk of personal isolation and created new challenges for individuals with families and social networks. Long work hours have created concerns about childcare, and the threat of occupational exposure to the novel SARS-CoV-2 virus and personal protective equipment shortages have increased concerns for personal safety and the risk of infecting family members. Too often, the result has been physical isolation from loved ones for extended periods and stigma associated with some of the most common and effective coping strategies for work-related stress pre-pandemic, such as social interactions, family gathering, and traveling.1,19,20

In the workplace, traditional drivers of burnout include the high patient acuity and turnover, regular contact with end-of-life care, long work hours, bureaucratic tasks that distract from clinical activities, workflow, and inefficiencies, including challenges navigating electronic medical records.21 The COVID-19 pandemic has magnified many of these issues, with drastic and unpredictable increases in workload and staffing challenges that have been exacerbated by illness and mandated quarantines. As a result, frontline healthcare workers have been forced to work longer hours and more shifts without appropriate rest, often with less control over their schedule, in a precarious working environment filled with supply shortages and challenging patient and family interactions driven by limited visitation policies and public misinformation.19 The uncertainty of best treatment practices, prolonged care requirements, and high morbidity and mortality associated with critical illness caused by COVID-19 all have added to the high risk of second victim syndrome. Patients and providers often suffer through these drawn-out, losing battles, and the lack of common critical care resources such as oxygen and mechanical ventilation, rationing of usual care, and watching patients die alone as a result of infection control restrictions have only exacerbated the exposure to moral injury.17,19

Fighting Burnout: An Evidence-Based Approach

It has been more than 20 years since the Institute of Medicine (IOM) first identified medical error as a leading cause of death in the United States. Experts have proposed that the epidemic of burnout in healthcare is a significant contributing factor to this ongoing problem.4 Although burnout starts with individuals, the solution to this major and growing problem requires a coordinated, systematic approach and leadership commitment at the organizational level.18

A detailed summary of our current understanding of system level solutions and areas for future research can be found in a white paper issued by the National Academy of Medicine in 2019. This expert panel called for healthcare organizations to create a strong culture of support for healthcare workers through leadership commitment to burnout prevention and management, including regular monitoring of organizational prevalence using validated burnout risk assessment tools, rapid implementation of existing evidence-based solutions using established quality improvement methods, and dedicated resources to support research in needed areas.20 Recently, the Critical Care Societies Collaborative summarized existing well-being initiatives among 74 professional societies.21 They also provided a series of specific recommendations for medical society responsibilities in this area, including the importance of supporting and sustaining member well-being, integrating well-being into everyday culture and society activities, and creating a safe environment for open discussion without fear of professional repercussions.

A more concise summary of recommended solutions to address the common challenges that interprofessional healthcare teams have faced during the COVID-19 pandemic is listed in Table 1. In addition to an emphasis on appropriate training, supplies, and support for personal and professional needs, strong bi-directional communication strategies and opportunities to participate in quality improvement to streamline workflow processes have been shown to strengthen staff engagement and reduce the risk of burnout. Specific burnout prevention efforts include leadership emphasis through policies, procedures, and role modeling; proactively addressing burnout triggers; fostering trust and mutual support among staff members; and providing restorative care programs.22 Efforts to address adverse outcomes and unanticipated events and to normalize second victim syndrome through peer support have been shown to be effective, sustainable, and cost-effective.23 This transformation requires collaboration at every leadership level to make a meaningful commitment to the so called “quadruple aim”: enhancing patient experiences, optimizing population health, lowering costs, and improving the work life of healthcare providers.24

Available evidence suggests that an adequate balance between stress and recovery is essential for humans to sustain a high level of performance. Although the best evidence in this area lies in appropriate staffing solutions and schedules that avoid long stretches of consecutive shifts, individual efforts to obtain adequate sleep, good nutrition, regular exercise, and stress management through mindfulness techniques and resiliency workshops remain a responsibility we all share. Prioritizing supportive relationships with team members, partners, coworkers, family, and friends is perhaps the best proven strategy to preserve individual resilience.25

If the challenges confronting our critical care community as a result of the COVID-19 pandemic become our “new normal,” a deliberate and systematic strategy to address burnout may become the defining challenge of this generation of healthcare workers. However, this strategy must be informed by an appropriate level of organizational support and meaningful prospective trials that define the necessary system interventions, barriers, and facilitators to inform the necessary system-level changes to achieve the “quadruple aim.” It is important to note that most of the current evidence on burnout heavily focuses on physicians and nurses, but our multiprofessional ICU team members, including critical care pharmacists, respiratory therapists, and other ICU support staff, cannot be neglected. The next steps are challenging but achievable, provided we approach them with a unified effort. 

References

  1. Kane L. Death by 1000 Cuts: 2021 Physician Burnout & Suicide Report. Medscape, 2021.
  2. Maslach C, Jackson SE. The measurement of experienced burnout. J Organizational Behavior 1981;2:99-113.
  3. Duckworth AL, Peterson C, Matthews MD, Kelly DR. Grit: Perseverance and passion for long-term goals. J Pers Soc Psychol 2007;92:1087-1101.
  4. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. National Academies Press (US); 2019 Oct. 23.
  5. Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clin Proc 2019;94:1681-1694.
  6. Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of burnout among physicians: A systematic review. JAMA 2018;320:1131-1150.
  7. Chuang CH, Tseng PC, Lin CY, et al. Burnout in the intensive care unit professionals: A systematic review. Medicine (Baltimore) 2016;95:e5629.
  8. Mental Health America, The Mental Health of Healthcare Workers in COVID-19. 2021. https://mhanational.org/mental-health-healthcare-workers-covid-19
  9. Moll V, Meissen H, Pappas S, et al. The coronavirus disease 2019 pandemic impacts burnout syndrome differently among multiprofessional critical care clinicians — A longitudinal survey study. Crit Care Med 2021; Sep 22. doi: 10.1097/CCM.0000000000005265. [Online ahead of print].
  10. Poncet MC, Toullic P, Papazian L, et al. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med 2007;175:698-704.
  11. Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.
  12. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: Suicidal ideation among American surgeons. Arch Surg 2011;146:54-62.
  13. Panagioti M, Geraghty A, Johnson J, et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction: A systematic review and meta-analysis. JAMA Intern Med 2018;178:1317-1331.
  14. Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med 2019;170:784-790.
  15. Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA 2020;323:2133-2134.
  16. Mealer M, Jones J, Newman J, et al. The presence of resilience is associated with a healthier psychological profile in intensive care unit (ICU) nurses: Results of a national survey. Int J Nurs Stud 2012;49:292-299.
  17. Azoulay E, De Waele J, Ferrer R, et al. Symptoms of burnout in intensive care unit specialists facing the COVID-19 outbreak. Ann Intensive Care 2020;10:110.
  18. Merlani P, Verdon M, Businger A, et al. Burnout in ICU caregivers: A multicenter study of factors associated to centers. Am J Respir Crit Care Med 2011;184:1140-1146.
  19. Moreno-Mulet C, Sansó N, Carrero-Planells A, et al. The impact of the COVID-19 pandemic on ICU healthcare professionals: A mixed methods study. Int J Environ Res Public Health 2021;18:9243.
  20. Catania G, Zanini M, Hayter M, et al. Lessons from Italian front-line nurses’ experiences during the COVID-19 pandemic: A qualitative descriptive study. J Nurs Manag 2021;29:404-411.
  21. Physician burnout: The root of the problem and the path to solutions. NEJM Catalyst June 2017.
  22. Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc 2015;90:432-440.
  23. Connors CA, Dukhanin V, Norvell M, Wu AW. RISE: Exploring volunteer retention and sustainability of a second victim support program. J Healthc Manag 2021;66:19-32.
  24. Bodenheimer T, Sinsky C. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Med 2014;12:573-576.
  25. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: Contributors, consequences and solutions. J Intern Med 2018;283:516-529.