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By Linda L. Chlan, RN, PhD, FAAN
Dean's Distinguished Professor of Symptom Management Research, The Ohio State University, College of Nursing
Dr. Chlan reports that she receives grant/research support from Hospira.
Clinicians who work in the intensive care unit (ICU) gravitate toward that particular setting because of the fast-paced, high-tech, challenging work in that environment. The life-and-death struggles can be exhilarating as well as emotionally and physically draining. This fast-paced, demanding, and stressful environment can also lead to a common syndrome among ICU clinicians: burnout. This special feature will describe burnout syndrome, identify factors that lead to burnout, discuss protective factors for allaying burnout, and provide some strategies that clinicians have used in their careers to maintain balance and resilience in a very demanding profession. While burnout occurs in any occupation, this paper will focus on ICU nurses and physicians.
CHARACTERISTICS OF BURNOUT
Burnout syndrome is a psychological state resulting from prolonged exposure to job stressors.1 While burnout is a debilitating condition that can develop in anyone, regardless of occupation, ICU clinicians are at greater risk of developing burnout due to the chronic stress of the immediate work environment and the inherent stressful nature of critical care.2 Defining burnout can be elusive, but there are several commonly accepted descriptions. Burnout is referred to as an occupation-induced psychological syndrome that is the extreme opposite of engagement.3 Others view burnout as disillusionment deep within the very essence of an individual — the collapse of the human spirit.4 There are three generally agreed-upon characteristics of burnout: 1) high emotional exhaustion; 2) high depersonalization, cynicism, or detachment; and 3) low levels of personal effectiveness or accomplishment.
ICU nurses have been studied more extensively over the past several years with respect to incidence of burnout due to their presence in large numbers on the critical care units and their close proximity to and responsibilities for around-the-clock patient care. However, the shortage of intensivists and the demands for 24/7 ICU coverage have led to an increased awareness and recognition of burnout among physicians as well. While it is impossible to survey every ICU nurse and physician worldwide to obtain an estimate of the percentage of clinicians with burnout syndrome, some cross-sectional surveys have reported 50% of ICU physicians and 33% of critical care nurses suffer from severe burnout syndrome.1
While both nurses and physicians experience burnout, development of the syndrome arises from different sources in the two groups of professionals. For intensivists, a high number of working hours (defined as number of night shifts and time since last vacation) is one of the primary contributors5 to burnout. For ICU nurses, the organizational culture and moral distress surrounding end-of-life issues were identified as the main contributors to burnout syndrome.1 Interestingly, conflicts in the ICU environment with colleagues or with interdisciplinary colleagues were predictors of burnout for both nurses and physicians.5
SNAPSHOT OF ICU NURSE BURNOUT
The main contributor to emotional exhaustion in ICU nurses is stress from the high patient acuity.2 Critical care nurses are asked to manage multiple aspects of patient care, typically care for two patients during a shift, and are expected to make sound clinical decisions and react quickly.
Another key contributor for ICU nurse burnout is the morally distressing situations encountered on a daily basis in the work setting. Moral distress can be defined as when people are unable to act in accordance with what they believe to be ethical, or when they act in a way that is contrary to their personal or professional values.6 The distress comes when one’s integrity and authenticity are undermined. Typically, moral distress is not identified as a contributor to ICU physician burnout as physicians are the professionals who make final decisions regarding a plan of care. While nurses are part of the care team, they usually are not involved in this final decision making about plans of care. Moral distress usually arises around the decision to continue aggressive treatment of patients when nurses feel the actions are futile. The unnecessary prolongation of life is one of the most stressful situations for ICU nurses, particularly when it goes against a patient’s known wishes.7
Critical care nurses many times are caregivers not only for patients but for family members as well. This can also contribute to emotional exhaustion and "compassion fatigue" when nurses identify on a personal level with patients and their family members in that they absorb their suffering and pain.8
Emotional exhaustion contributes to depersonalization, which is a coping mechanism in response to emotional overload.2 Nurses become detached from patients, family members, and their colleagues; they put distance between themselves and the work setting. A cynical attitude may develop in response to feeling powerless and prevent the nurse from any action.2
Lastly, feelings of ineffectiveness and lack of personal accomplishments also contribute to burnout in ICU nurses. Many ICU nurses have very high standards of care and expectations for themselves that they may not be able to meet.2 Lack of personal accomplishment can also arise when nurses perceive that physicians do not value their viewpoint and expertise, and are omitted from decision making about patient care.
SNAPSHOT OF PHYSICIAN BURNOUT
Deterioration of physician well-being from excessive stress is a widespread problem.9 There is a direct link with burnout to substance abuse (alcohol and drugs), job turnover, marital problems, and low morale.9 Physicians face pressures from many sources: recognition from peers as being a hard worker, service to others before self, exhaustion leading to loss of empathy, and blaming patients for their conditions. Other factors such as steadily declining incomes and the devaluation of the doctor-patient relationship also contribute to burnout. Many physicians feel like they have to spend too much time on the "business" side of medicine.9 In a survey by Chopra and colleagues, 80% of practicing physicians reported moderate-to-high levels of emotional exhaustion, 93% moderate-to-high levels of depersonalization, and 75% low-to-moderate levels of personal achievement.10 Among intensivists, a heavy number of hours worked without time off and conflicts with fellow intensivists or nurses were associated with higher burnout scores.5
In addition, doctors have high rates of mental health problems, including depression, misuse of prescription drugs, and burnout, particularly among female physicians.11 Higher rates of mental health problems appear to be more prevalent among younger physicians in the 30-39 year age category,11 which does not bode well for the health and well-being among the physicians of tomorrow.
Risks factors contributing to potential mental health problems among physicians include clinical occupational factors and structural occupational factors.11 Clinical factors are those stressors that emanate from the emotional demands of working with patients and dealing with anxiety, suffering, and death.11 Structural factors contributing to risk of mental health issues for physicians include heavy workload and working hours, sleep deprivation, and unpredictable hours contributing to psychological distress.11 Individual personality factors such as being self-critical and engaging in unhelpful coping strategies (i.e., emotional distancing) can contribute to psychological distress, burnout, and mental health problems.11
WHAT ARE THE CONSEQUENCES OF BURNOUT?
Perhaps the most prominent of the consequences of burnout syndrome among ICU professionals is that burnout can lead to staff turnover and lost productivity. Burnout can lead ICU nurses to consider leaving the profession entirely, which does not remedy the continued and projected nursing shortage. Patient care and communication can suffer when ICU professionals are "disengaged" from their colleagues, patients, family, and work environments. The work of Brooks and colleagues details the mental health problems facing physicians who are emotionally exhausted, including addiction to drugs and alcohol.11 Suicide is also an outcome of mental health problems tied to emotional exhaustion.12
The stakes are too high not to be concerned about ICU clinicians’ mental health and well-being. While the evidence presented thus far may seem dismal, there is hope to remedy burnout syndrome. Nurses and physicians can personally employ a number of strategies to buffer against burnout and to strengthen their own mental health. Some of these strategies are described below.
PROTECTIVE AND PROACTIVE STRATEGIES FOR BURNOUT SYNDROME
For ICU nurses, a supportive environment where nurses feel their voice is heard and their opinions are respected is key for preventing nurse burnout.2 The availability of counseling services and time to debrief are also important factors in a supportive work environment for nurses. Nurses need to take professional responsibility to support one another in their everyday work environments. This can be accomplished with a "buddy system" where nurses can provide encouragement and support to one another.2 Recognizing nurses for their many contributions to patient and family care with meaningful awards and recognitions are also important burnout-buffering strategies.
Nurses need to take personal responsibility for their own health and well-being. The tried and true strategies of a healthy lifestyle, taking breaks and vacations, eating a balanced diet, and getting enough rest and sleep apply to ICU nurses as well as every other group of professionals.
The presence of resilience has been found to play a role in healthier psychological profiles of ICU nurses and also in physicians, and can serve as a buffer for burnout. Resilience is a multidimensional characteristic that embodies the personal qualities that enable one to thrive in the face of adversity.13,14 Resilience can be learned through cognitive behavioral therapy and factors such as temperament, family bonds, external support systems, and personal qualities (optimism, faith, striving towards personal goals).14
For physicians, the ability to remain focused on what is important in life contributes to well-being.9 Strategies such as setting limits and self-awareness of boundaries, spending time with friends and family, maintaining self-care through exercise, maintaining self-care through relaxation, and having a healthy philosophical outlook through humor are all effective in buffering against physician burnout.9 Among surgeons who responded to a national survey, those who placed a greater emphasis on work-life balance, finding meaning in work, maintaining a positive outlook, and focusing on what is important in life were less likely to have burnout.15
SUMMARY AND CONCLUSIONS
Burnout is a common syndrome among ICU nurses and physicians. Burnout can lead to disengagement and cause skilled clinicians to leave the ICU setting or their professions altogether, particularly among nurses. The good news is that there are a number of evidence-based strategies for ICU clinicians to integrate into their daily lives to provide a buffer against burnout.
The most essential skill for any ICU professional may be finding personal balance. This idea of balance will mean different things to different ICU professionals. While not rocket science, the time-honored methods of setting limits, spending quality time with friends and family, exercising, relaxing, and maintaining a sense of humor can go a long way to promoting personal health and well-being. There will never be enough ICU physicians and nurses, and there will never be enough hours in the day to accomplish everything on our "to do "lists. We need to care for ourselves and encourage our colleagues to do so as well. Only then will we have the emotional and physical energy to effectively care for the increasing numbers and acuity of our patients and their family members. I challenge every ICU professional to take responsibility to recognize his/her own personal limits, take mini-recovery breaks, practice relaxation such as mindfulness or deep breathing, exercise regularly, rest and get adequate sleep, eat a healthy diet, and engage in enjoyable leisure activities. No one is invincible! We should not expect this of ourselves or our colleagues.
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