An Official Critical Care Societies Collaborative Statement

EJRC REVIEW

Burnout syndrome (BOS) is a work-related constellation of symptoms and signs that usually occurs in individuals with no history of psychological or psychiatric disorders [1]. BOS is triggered by a discrepancy between the expectations and ideals of the employee and the actual requirements of his position. Symptoms of BOS typically develop gradually. In the initial stages of BOS individuals feel emotional stress and increasing job related disillusionment [2]. They subsequently lose the ability to adapt to the work environment and display negative attitudes toward their job, their coworkers, and their patients. Eventually, the three classic symptoms of BOS develop: exhaustion, depersonalisation, and reduced personal accomplishment [3]. Exhaustion is generalised fatigue that can be related to devoting excessive time and effort to a task or project that is not perceived to be beneficial. Depersonalisation is a distant or indifferent attitude toward work. It manifests as negative, callous, and cynical behaviors or interaction with colleagues or patients in an impersonal manner. Reduced personal accomplishment is the tendency to negatively evaluate the worth of one’s work, feeling insufficient regarding the ability to perform one’s job, and a generalised poor professional self-esteem.

BOS is most commonly diagnosed by using the Maslach Burnout Inventory (MBI) [3], which is a 22-item, self-report questionnaire that asks respondents to indicate the frequency with which they experience certain feelings related to their job.

Working in an ICU can be especially stressful because of the high patient morbidity and mortality, challenging daily work routines, and regular encounters with traumatic and ethical issues. This level of nearly continuous and excessive stress can rapidly accelerate when caregivers perceive that there is insufficient time or limited resources to properly care for patients. Having an inadequate support system outside of the work environment has also been associated with high rates of BOS [4, 5]. Until recently, the critical care community was relatively unaware of the harmful effects of working in a stressful ICU environment [6, 7].  Unfortunately, critical care healthcare professionals have one of the highest rates of BOS (ie, > 50%), and development of this disorder may adversely affect the ability to care for patients properly [8].

"BOS…. is especially common in individuals who care for critically ill patients. BOS is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care." 

The authors intended to raise awareness of BOS as this has important implications for clinical care. That’s why the Critical Care Societies Collaborative (CCSC) (that comprises four major US professional and scientific Societies) convened a working group that developed this call to action to acknowledge the importance of BOS.

For this study, the investigators searched the Cochrane Library and Medline by using PubMed for published research relevant to BOS. A variety of search terms were entered. Pertinent review articles, editorials, books, and references from identified articles were also reviewed.

In the resulting article published in CHEST [9], the authors review the diagnostic criteria, prevalence, causative factors, and consequences of BOS. This article also discusses potential interventions that may be used to prevent and treat BOS, namely interdisciplinary discussions among critical care physicians and nurses that encourage ethical team deliberations [10]. Finally, it urges multiple stakeholders to help mitigate the development of BOS and diminish the harmful consequences of BOS, both for critical care healthcare professionals and for patients.

Study Strengths & Limitations

The paper has several strengths, namely it: (1) clearly summarises the available literature regarding the diagnostic criteria, prevalence, causative factors, and consequences of BOS and related conditions; (2) raises awareness of BOS within the critical care community, and (3) emphasises the importance of informing multiple stakeholders of their potential roles in reducing BOS and its deleterious consequences in healthcare professionals and their critically ill patients.

This paper also highlights limitations on the published literature about this subject, namely: (1) the diagnostic criteria for BOS vary across studies, making comparisons difficult from one study to another as the assessment instrument accurate cutoff values for critical care healthcare providers have not been determined; (2) other conditions may overlap with BOS;  (3) most of the previous BOS-related literature has focused on the disorder’s negative consequences as they correspond to patient-centric outcome measures, including patient safety, satisfaction, and quality of care. However, promoting wellness in healthcare providers is also essential; (4) currently, there are no large randomised controlled trials that have examined strategies to prevent or treat BOS in critical care healthcare professionals; (5) furthermore research in this area is grossly underfunded. 

Take Home Messages 

• BOS occurs in all types of healthcare professionals and is especially common in individuals who care for critically ill patients. 
• The development of BOS is related to an imbalance of personal characteristics of the employee and work-related issues or other organisational factors. 
• BOS is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care.
• Critical care healthcare professionals should be taught how to recognise the risk factors for BOS and how to seek assistance when needed. This call to action hopefully enhances the critical care community’s interest in reducing the prevalence of BOS.
• Collectively, ICU teams should improve their ability to function as a group, respect each other, and reduce triggers of BOS. 
• Academic institutions play an important role in career counseling. as well as Professional societies, who should educate members about BOS. Promoting wellness in healthcare providers is essential.
• Potential strategies that may prevent and treat critical care-related BOS can be divided into two categories: (1) interventions focused on enhancing the ICU environment, and (2) interventions focused on helping individuals cope with their environment. 
• Collectively, healthy ICU work environments need to be created that ultimately and, most importantly, improve patients’ quality of care.

This article review was submitted by ESICM Journal Review Club member Prof Carla Teixeira (Santo António Hospital, Porto, Portugal) on behalf of the Ethics section.

References

1. Maslach C, Leiter MP. The Truth About Burnout. San Francisco, CA: Josset-Bass Publishers; 1997.
2. Edelwich J, Brodsky A. Burn-out: Stages of Disillusionment in the Helping Professions. New York, NY: Human Services Press; 1980.
3. Maslach C, Jackson SE. MBI: Maslach Burnout Inventory; Manual Research Edition. Palo Alto, CA: Consulting Psychologists Press; 1986.
4. 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(10):1140-1146.
5. Teixeira C, Ribeiro O, Fonseca AM, Carvalho AS. Burnout in intensive care units-a consideration of the possible prevalence and frequency of new risk factors: a descriptive correlational multicentre study. BMC Anesthesiol. 2013; 13(1):38.
6.  Azoulay E, Herridge M. Understanding ICU staff burnout: the show must go on. Am J Respir Crit Care Med. 2011;184(10):1099-1100.
7. Embriaco N, Papazian L, Kentish-Barnes N, Pochard F, Azoulay E. Burnout syndrome among critical care healthcare workers. Curr Opin Crit Care. 2007; 13(5):482-488.
8. Peckham C. Medscape physician lifestyle report 2015. http://www. medscape.com/features/slideshow/lifestyle/2015/public/overview#1. Accessed January 26, 2015.
9. Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. An official Critical Care Societies Collaborative statement: burnout syndrome in critical care healthcare professionals: a call for action. CHEST 2016; 150(1):17-26
10. Teixeira C, Ribeiro O, Fonseca AM, Carvalho AS. Ethical decision making in intensive care units: a burnout risk factor? Results from a multicentre study conducted with physicians and nurses. J Med Ethics. 2014; 40(2):97-103.