Burnout in the ICU – Still a Work in Progress

Burnout of the healthcare workforce, and particularly of critical care clinicians, is an active global concern, which has been exacerbated by the COVID-19 pandemic. We present the definition and factors contributing to burnout specifically in the ICU, discuss the misconceptions around the use of burnout measurement tools, and highlight the challenges posed in conducting research and proposing solutions for this complex issue.

Introduction

The Intensive Care Unit (ICU) is a high-stakes and high-emotion environment, where critically unwell patients face life-and-death situations. Physicians frequently make challenging decisions, especially since most deaths in ICU follow decisions to limit life-sustaining treatment (Avidan et al. 2021). Nurses and allied health professionals care daily for unwell patients of all ages, while simultaneously supporting their anxious and often bereaved families. Barring the emotional elements of working in the ICU, there are a number of other factors common to critical care, which may increase the stress experienced by the healthcare professionals (HCP), such as long working hours, frequent interruptions and alarms, high workload, disrupted awake/ sleep cycle and physical fatigue (Curtis and Puntillo 2007). This high level of chronic stress has been linked to increased levels of burnout, an issue that has reached epidemic proportions, especially since the COVID-19 pandemic (Saravanan et al. 2023).

Clinician burnout may have particularly important implications in critical care due to the nature of the quality of care and safety of a very vulnerable cohort of patients. Although a clear association between the consequences of burnout and patient safety in ICU is unclear, there is emerging evidence that overall physician burnout doubles patient safety incidents (Hodkinson et al. 2022). Reported unfavourable events include patient dissatisfaction, increased patient and family complaints, and compromised quality of care (Hall et al. 2016). Interestingly, the results are not unequivocal, as there are studies that have found no influence of burnout on the occurrence of medical errors, nor did they identify an association between the disease and patient safety culture scores (Welp et al. 2016).

Our review aims to summarise the definition and factors contributing to burnout specifically in the ICU, but also highlight the challenges posed in conducting research and proposing solutions for this complex issue.

Definition

Burnout was introduced into psychology in 1974, coining a term used in a novel by Graham Green, "A Case of Burnout" (1960). Maslach and Jackson (1986) reformulated the concept, providing a more specific and operational definition of burnout as a psychological syndrome characterised by three distinct traits: emotional exhaustion, cynicism or depersonalisation and reduced personal achievement (Table 1). Even from the early approaches to a definition, the explicit assumption was that people could experience various patterns of burnout, which might change at different points in time.

In 2019, the World Health Organization (WHO) finally included burnout in its International Classification of Diseases (ICD-10), describing it as a ‘syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed’ (Harrison et al. 2021; Drösler et al. 2021).

The focus on the work context is highlighted as the difference between burnout and depression, as the latter tends to pervade every domain of a person's life and not just the work environment (Maslach et al. 2001). Similarly, there are notable differences in presentation between burnout and stress (Table 2).

Causes of Burnout

Factors leading to burnout have been categorised into intrinsic/personal and extrinsic/organisational (Tung et al. 2020). Interestingly, no clear connection has been established between personal characteristics and the development of burnout, with studies reporting conflicting results. For example, although older clinician age has been found to have a positive association (Michalsen and Hillert 2011; O’Connor et al. 2018), the impact of age is far from straightforward, as different studies have shown the opposite results (Adriaenssens et al. 2015). Similar heterogeneity is reported for gender, professional role, years of experience and social characteristics (Michalsen and Hillert 2011; van Mol et al. 2015).

The impact of organisational factors is more straightforward, with several job-related elements being associated with increased burnout risk. These include working patterns (e.g., shift work, number of working hours); ICU characteristics (e.g., number of beds, annual number of admissions, patient severity); work environment (e.g., presence of conflict, lack of control over one’s decisions/progression, lack of leadership and role models) (Terzi et al. 2025; Teixeira et al. 2014; Wahlin et al. 2010).

Measuring Burnout

The most widely used, valid and reproducible instrument to assess burnout in healthcare professionals is the Maslach Burnout Inventory (MBI) (Maslach et al. 1996; Maslach et al. 2001), which contributed decisively to its conceptualisation and empirical study. The MBI is a 22-item questionnaire which asks respondents to indicate on a seven-point Likert scale the frequency with which they experience certain feelings related to their work. It evaluates three domains of burnout: emotional exhaustion, depersonalisation and reduced personal achievement. The emotional exhaustion subscale (nine items) assesses feelings of being emotionally overextended and exhausted by one’s work. The depersonalisation subscale (five items) measures how empathetic and caring is the response towards patients, whereas the subscale of personal achievement (eight items) assesses feelings of competence and achievement in one’s work.

The instrument was designed to provide a continuum of frequency from more positive to more negative, rather than an arbitrary dividing point between 'present' and 'absent' (Leiter and Maslach 2016). For this reason, the previous classifications (‘high’, ‘moderate’ and ‘low’) that were calculated by splitting any normative population into thirds were removed from the fourth edition of the MBI Manual and all associated MBI materials, as they had no diagnostic validity.

Other instruments have also been used, including the 16-item Oldenburg Burnout Inventory, which can be applied to any occupational group and unlike the MBI is free to use (National Academy of Medicine 2022); the 19-item Copenhagen Burnout Inventory, which was developed to address shortcomings of the MBI, including its proprietary nature and difficulty in translating into other languages (Kristensen et al. 2005); and the 23-item Burnout Assessment Tool, which yields a single, composite burnout score (Schaufeli et al. 2020).

Challenges With the Burnout Concept

Although the detrimental impact of burnout on well-being and absenteeism is almost universally accepted, significant challenges have been identified both with its definition and measurement. First, until the WHO 2021 definition, there were difficulties in the medical classification of the condition, whether it was a syndrome or disease or a sub-classification of another issue. This is important, as the lack of clear definition and understanding has led to fragmented research, disparate results and ineffective policy responses throughout Europe and the U.S.

The three different dimensions of burnout have also led to complexities in its measurement outside of the academic sphere, with attempts to translate the continuous scores of a research measure into a dichotomous burnout classification (Leiter and Maslach 2016). One approach was to oversimplify the instrument, either by adding the three scores together or choosing only one dimension (most commonly exhaustion) to decide whether a healthcare professional was burned out or not. These modifications led to heterogeneous results, sometimes implicitly proposing a new definition of burnout. The oversimplification was driven by the need for a clear 'diagnosis' that would enable the proposition of preventive and therapeutic strategies, with significant implications for insurance policies and public health funding. 

Linked with the attempt to use the burnout assessment instruments as clinical diagnostic tools is the arbitrary use of cut-off points, ‘diagnosing’ healthcare providers as burned out or categorising them in ‘high’, ‘moderate’, and ‘low’ groups. The lack of an established level of burnout that correlates with negative outcomes is evident in the relevant literature and produces contrasting results. The pooled proportion of burnout in healthcare professionals has been quoted as 39% with very wide confidence intervals (95% CI 25–53%) and high heterogeneity (Nagarajan et al. 2024), with similar results seen in ICU clinicians (prevalence 0.41, range 0.15–0.71) (Papazian et al. 2023). The reported heterogeneity is concerning, as most studies did not explicitly give cut-off points for each scale; hence, results should be interpreted with caution, limiting meaningful comparisons.

Addressing Burnout

Several strategies have been proposed as effective for the prevention of burnout and promotion of work-related well-being, and they include both individual and organisational interventions (Edú-Valsania et al. 2022).

a. Interventions targeted at the individual

Physical exercise: Physical activity is often associated with a reduced risk of burnout, particularly in the domains of emotional exhaustion and depersonalisation, although significant heterogeneity in definitions, measurements, and analyses was observed (Mincarone et al. 2024).

Mindfulness training: Relaxation and mindfulness training, either practiced individually or with the help of a psychologist, may reduce burnout rates (van Mol et al. 2015).

Psychotherapy: Psychotherapeutic treatment of burnout may be of use when addressing the consequences of the syndrome. Psychotherapeutic treatment for burnout typically consists of developing emotional self-regulation and relaxation skills, problem-solving, and development of self-efficacy and assertiveness, and is generally based on the principles of cognitive-behavioural therapy (Ahola et al. 2017).

Time/workload management: The risk of burnout has been associated with clinicians feeling they lack the time to fulfil all their responsibilities. Interventions to address this include task prioritisation and organisation, as well as reduction of the time spent on ICU mandatory tasks (Lilly et al. 2019).

Job crafting: This intervention proposes a consistent and active modification of one's job and is commonly encountered in non-healthcare-focused literature. Table 3 describes four types of adjustments that can be made (Bakker et al. 2018).

Many of the strategies discussed pose particular challenges to those working in critical care. The emotional impact of ICU care is unavoidable, and strategies such as time management, can have limited impact due to the frequently emergency nature of the work. Similarly, nurses often work with one person for an entire shift, with little opportunity to step away. The highly emotional ICU environment is based on shiftwork, which predisposes to burnout, whereas downtime is dependent on social circumstances and hobbies/interests that cannot be easily modifiable. Hence, organisational level interventions are bound to have more significant effects when compared with individual-directed interventions (Panagioti et al. 2017)

b. Interventions targeted at the organisation

The realisation that organisational factors weigh more in the development of burnout than individual ones has led to actions that target systemic issues. Different categorisations have been proposed, e.g. the nine organisational strategies by Shanafelt et al, 2017:

• Acknowledge and assess the problem
• Harness the power of leadership
• Develop and implement targeted interventions
• Cultivate community at work
• Use rewards and incentives wisely
• Align values and strengthen culture
• Promote flexibility and work-life integration
• Provide resources to promote resilience and self-care
• Facilitate and fund organisational science

Along the same lines are the strategies proposed to align with the six areas of work life (Leiter & Maslach, 1999):

The increasing number of actions, statements and guidance around the organisational aspects of burnout highlight the emerging awareness around the topic (Moss et al. 2016; Terzi et al. 2025) Addressing burnout is the shared responsibility of clinicians and the organisations in which they work in, since interventions that solely target the individual are flawed and bound to be unsuccessful. Organisations need to overcome artificial barriers, such as the assumption that all interventions aiming at reducing burnout will be cost-incurring or counterproductive.

Conclusion

Pressure on the healthcare workforce is an active global concern, which is particularly evident in critical care and exacerbated by the COVID-19 pandemic. Burnout is not a personal failure or disease; it is a syndrome directly related to chronic workplace stress. A host of individual and organisational factors have been associated with the development of burnout; however, conflicting reports still exist. Several misconceptions and challenges around the use of burnout measurement tools (inability to distinguish between work stress and nonwork stress, lack of a universal cut-off point for severe burnout or a clear link between a score and healthcare outcomes) continue to exist. For future research to be able to inform individual or structural interventions for the prevention or management of burnout, it requires standardised definitions, which will enable appropriate comparisons and a better understanding of burnout variations in different clinician subgroups.

Conflict of Interest

None.