The Disaster “Cascade”: Burnout Syndrome in the ICU

Authors

Ronald Pauldine,MD

Assistant Professor

Department of Anesthesiology and Critical Care Medicine

Johns Hopkins Bayview, Medical Center, Baltimore

Todd Dorman,MD, FCCM

Associate Professor

Department of Anesthesiology and Critical Care Medicine

Johns Hopkins University, School of Medicine, Baltimore

[email protected]

Introduction

Burnout syndrome is a psychological response to chronic emotional and interpersonal stressors at work and includes three dimensions; overwhelming exhaustion, cynicism or detachment from the job and inefficiency or a sense of lack of accomplishment (Maslach et al. 2001). Burnout has been described since the mid-1970s, and it is now well recognized that burnout syndrome can occur in a variety of occupational environments. However, the intensive care unit puts personnel at particular risk. For instance, it is underscored by a 33% incidence of burnout syndrome in ICU nurses in France (Poncet et al. 2006). We will briefly review elements of, and risk factors for burnout, as well as strategies for preventing burnout.

Elements of Burnout

When workers complain about burnout, they usually refer to the exhaustion component. Not surprisingly, this aspect is associated with work overload, which includes emotional overload, conditions common in the ICU. The second element of burnout is depersonalization or cynicism, which is usually an adaptive response to exhaustion. The third element, inefficiency, may result sequentially from exhaustion and cynicism or occur concurrently, especially where there is a lack of resources (Maslach et al. 2001). Some aspects of burnout resemble depression. However, burnout is specifically related to work, whereas depression is a generalized disorder. Burnout and depression remain separate entities, but they can precede each other.

Risk Factors

Prolonged exposure to chronic stressors is a risk factor for burnout. Environmental factors have been implicated in increasing staff stress. These include the poor ergonomic design of many units, less than ideal lighting, positioning of equipment resulting in the familiar “spaghetti syndrome” and the ever present audible alarms (Donchin and Seagull 2002). The emotional workload in the ICU is considerable, given the general nature of critical care, intense interaction with families, and relative frequency of dealing with end-of-life issues. Other stressors include those associated with shift work and the variable quality and effectiveness of communication. Outright conflict between stakeholders in the ICU can contribute.

Burnout is more strongly related to stress in the work environment than to specific individual factors. However, burnout is more common in people who exhibit Type-A behavior, low levels of hardiness, individuals maintaining an external locus of control and those with passive, avoidant coping styles (Maslach et al. 2001). In addition, trainees may be especially vulnerable (Thomas 2004).

Significance

The negative impact of burnout on daily operations in the ICU can be dramatic. Studies have documented a relationship between burnout and substandard patient care provided by trainees (Shanafelt et al. 2002) and irrational thinking patterns in nurses (Balevre 2001). Burnout increases physical complaints resulting in the use of sick leave ( To p p i n e n - Tanner et al. 2005). The attitudes of burned-out staff may influence other staff members negatively further degrading the work environment (Bakker et al. 2005). These factors contribute to turnover and create problems with recruiting, training

and retention of staff.

Prevention and Intervention

Efforts to prevent burnout can be directed at modifiable environmental and individual factors. Those factors most commonly are centered on the physical work environment, communication and fairness. It is important to have an ICU culture that supports the staff at all levels with material and emotional resources and allows for professional growth. Organizational support can be provided in areas such as proper training, orientation, peer and supervisor support and provision of attainable rewards (Taormina and Law 2000). Individual factors can be addressed through attempts to improve coping skills, which can modify the response to stress but cannot remove it. Ultimately, creating a positive work environment with adequate support for staff appears to be the best approach to preventing burnout and avoiding its deleterious effects on ICU care.