Burnout and resiliency

Pearls

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Both individual and organizational measures can be used to mitigate burnout and build resilience.
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Organizational strategies to promote a healthy work environment include team debriefings after critical events, enabling self-scheduling and time off, limiting the number of consecutive shifts worked, and offering team communication training.
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Individual measures to mitigate burnout include self-care measures such as taking vacation time, ensuring adequate sleep and rest, exercise, healthy eating, and resiliency training.

Burnout in healthcare professionals can result from prolonged chronic emotional and interpersonal stressors. It has been defined as a constellation of three dimensions: emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment. A number of recent national initiatives and ongoing research highlight the value of proactive strategies for building resilience and promoting a healthy work environment to mitigate burnout in critical care clinicians. The National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience has raised the awareness of the importance of addressing clinician well-being to prevent burnout. National surveys continue to demonstrate the high prevalence of burnout among healthcare providers. In a recent Medscape survey on physician burnout, with more than 15,500 physicians surveyed (61% were men and 39% were women), 44% of physicians reported feeling burned out and over 26 specialties had a burnout rate of 33% or higher. Among factors reported to impact burnout negatively, physicians most frequently identified having too many administrative responsibilities, long work hours, required documentation in the electronic health record, lack of respect, and insufficient compensation. The statistics are similar for many members of the interdisciplinary critical care team, including critical care nurses, pharmacists, advanced practice nurses, and physician assistants, revealing that burnout among critical care providers is significant.

Burnout and compassion fatigue in pediatric critical care providers

Several studies have addressed burnout and psychologic distress among pediatric critical care physicians. In a recent national survey of 253 practitioners, 49% reported high burnout scores in at least one of the three subscales of the Maslach Burnout Inventory and 21% reported severe burnout. The risk of burnout was almost two times more in women physicians (odds ratio, 1.97; 95% confidence interval, 1.2–3.4). No other associations between personal or practice characteristics and burnout were found; however, regular exercise appeared to be protective. With respect to psychologic distress, 30.5% of all participants and 69% of those who experienced severe burnout screened positive. Almost 90% of the physicians who reported severe burnout had considered leaving their practice. The results of the study demonstrate that a large proportion of pediatric critical care physicians experience burnout and, of those who do, the vast majority have contemplated leaving the profession. As such, physician burnout poses a significant risk to the future of the pediatric critical care physician workforce.

The term compassion fatigue is frequently used interchangeably with burnout , but they are not the same thing. Compassion fatigue results when clinicians are exposed to repeated interactions requiring high levels of empathy with distressed patients, which can be a significant contributing factor to caregiver burnout. Compassion fatigue can lead to physical, emotional, and work-related symptoms that can affect patient care and personal relationships. Broadly, compassion fatigue results in a reduced capacity and interest in being empathetic for those who are suffering and can be framed as the clinician’s emotional and physical cost of caring. In a recent national survey of 609 pediatric critical care fellows and attending physicians, the prevalence of compassion fatigue was found to be 25.7%, and the prevalence of burnout was 23.2%. Burnout score, emotional depletion, and distress about a patient and/or the physical work environment were each significant determinants of higher compassion fatigue scores, while the compassion fatigue score, distress about administrative issues and/or coworkers, and the belief that self-care is not a priority were each significant determinants of higher burnout scores. Not surprisingly, the investigators found that chronic exposure to patient and family distress placed pediatric critical care physicians at risk for compassion fatigue.

Several factors specific to pediatric critical care practice can increase the risk of burnout. These factors include providing care to children with complex, potentially life-threatening medical conditions; exposure to critically ill children who are perceived as suffering; interacting with families during crisis situations; and engaging in difficult conversations related to transitioning the pediatric patient from curative care to palliative care around end of life ( Box 22.1 ). Both pediatric and adult critical care nurses identify that moral distress is a significant factor impacting burnout in the intensive care unit (ICU), along with providing end-of-life care. While the death of any patient is traumatic, the death of a child is often more distressing for pediatric critical care clinicians.

• BOX 22.1

Risk Factors for Burnout in Pediatric Critical Care Clinicians

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Stressful work environment
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Workload
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Work hours/demands
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Managing critical care pediatric patients
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Ethical and end-of-life issues in a pediatric population
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Dealing with families of pediatric patients in distress or at end of life
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Emotional exhaustion
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Depersonalization
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Lack of personal accomplishment
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Compassion fatigue
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Lack of fulfillment in work

A recent task force report from the Academic Leaders in Critical Care Medicine Task Force of the Society of Critical Care Medicine identified that the common risk factors for burnout among ICU physicians and nurses are as follows: (1) personal characteristics, such as younger age of nurses and female gender among intensivists; (2) organizational factors, such as the volume and timing of clinical work, including number of nights and consecutive work days; (3) quality of working relationships, such as interpersonal conflicts; and (4) end-of-life issues, such as providing care to the dying patient. Similarly, burnout has been found to increase as pediatric critical care providers spend more nights per month in the hospital. Taken together, these findings suggest that the current demands of the ICU physical environment along with models of both physician and nurse staffing are contributing to the high rate of burnout in pediatric critical care.

Critical care societies work to address burnout

The Critical Care Societies Collaborative (CCSC), which is composed of the four major critical care–focused US professional and scientific societies—the American Association of Critical-Care Nurses, American College of Chest Physicians, American Thoracic Society, and the Society of Critical Care Medicine—recognized the importance of addressing burnout among critical care professionals and published a call to action in 2016 that reviewed relevant research and addressed potential interventions for mitigating burnout. The call to action highlighted the benefit of destigmatizing burnout and linking the consequence of burnout to the root cause of working in a high-stress profession rather than as a character flaw or weakness, a common misperception cited in the literature. Additionally, the publication recommends that critical care healthcare professionals should be taught how to recognize the risk factors for burnout, mitigate them if able, and taught how to seek assistance when professional support is needed. Finally, the call to action stresses that organizations need to prioritize and promote workplace wellness and encourage healthcare professionals to take individual accountability for maintaining their own emotional and physical health and resiliency.

Building on the call to action, the CCSC recently sponsored a national summit on the management and prevention of burnout and engaged 55 invited experts in the fields of psychology, sociology, employee assistance, integrative medicine, psychiatry, suicide prevention, occupational medicine, nursing, social work, employee assistance, sleep medicine, bereavement support, among others, to offer expertise and formulate approaches that accelerate actions to address and prevent burnout. Through a series of breakout groups, the summit focused on (1) factors influencing burnout among ICU professionals, (2) identifying burnout in ICU professionals, (3) the value of organizational interventions in addressing burnout, (4) the value of individual interventions in addressing burnout, and (5) advancing the research agenda.

The national summit addressed the importance of raising awareness among critical care clinicians and key stakeholders, advocating for workplace changes to promote healthy work environments, and promoting research to explore practical strategies further to address, mitigate, and prevent burnout.

As a follow-up to the national summit, the CCSC conducted a national survey of 680 CCSC members and identified several initiatives currently being implemented both at the hospital and unit levels to build clinician resilience and address burnout prevention. These include the development of unit-based wellness committees, support groups, ICU team-building training, physical exercise, yoga or meditation, and organizational measures such as healthy food choices on campus, on-site exercise facilities, and mindfulness-based stress-reduction courses. The literature also reflects a growing number of novel initiatives, such as the creation of Chief Wellness Officer positions. This officer is charged with addressing clinician resilience on a broad basis, initiating community-building activities implemented by clinicians, such as huddles, social outings, group dinners, and peer support groups ( Box 22.2 ). ^,

• BOX 22.2

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