The physiologic, cognitive, and affective facets of stress are based on the seminal early work of Selye [9] on the general adaptation syndrome. Selye defined stress as the nonspecific result of any demand on the body, and observed that different organisms and biological systems respond to stress in a stereotyped and predictable three-part pattern. The initial alarm reaction (characterized by activation of the sympathetic nervous system and various hormonal, immunologic, and psychological responses) is followed by the stage of resistance, during which the organism establishes a temporary homeostasis by marshalling various reserves to adapt to the new situation. However, the body’s ability to adapt is finite, and, with continued exposure to the stressor, its reserves become depleted and the organism enters a stage of exhaustion.

Researchers in biology and sociology have expanded this work to encompass processes ranging from individual cellular responses to stress, to the reactions of individuals and social systems to external and internal stressors. The study of occupational stress (i.e., stress due to one’s work situation) has grown substantially since the 1960s, expanding to professions ranging from factory work to nursing. Research during the past four decades has consistently demonstrated the significant adverse impact of excessive occupational stress on physical health, mental health, and decision-making. Regardless of the field, low job satisfaction is often predicted by a small number of factors: little participation in decision-making, ambiguity about job security, poor use of skills, and lack of clarity about role. These stressors are consistent with the demand–control model of the effects of job demands on worker’s well-being. This model predicts that the fewer demands and more control a worker has on the job, the less stress he will experience [10,11]. For example, an analysis from the Swedish National Registry of 958,000 people found that hospitalization rates for myocardial infarction (MI) were higher among men and women with high-demand, low-control jobs [11].

Other well-recognized occupational stressors include noise-related stress, dangerousness of the work environment, nonstandard work hours, and excessive fatigue [10]. Of these stressors, work overload and a poor social environment at work are the most significant determinants of work-related health problems. Cross-sectional associations between work overload and health complaints are consistently reported [12,13]. Furthermore, work overload and overall low job satisfaction are strongly associated with the development of psychiatric (particularly affective) problems. A meta-analysis of job satisfaction and health outcomes examined 485 studies (267,995 individuals) and concluded that poor job satisfaction was strongly associated with the development of depressive and other affective illnesses [14].

In addition to physical and mental health, decision making also can be adversely affected by high levels of stress. Awareness of one’s limited knowledge and problem-solving capabilities, fear that bad outcomes will occur regardless of which choice is made, worry about making a fool of oneself, and fear of loss of self-esteem if the decision is wrong can force decision-makers to come to “premature closure.” Fearing a negative assessment of their sense of helplessness, otherwise rational decision-makers foreclose the decisional dilemma before a search for, and an unbiased assimilation of, all relevant information and generation and careful appraisal of all alternatives can be completed [15].

Such premature closure can lead to incorrect or even harmful decisions [15]. For example, in their classic study of patients with acute MI, Hackett and Cassem [16] noted that the majority of patients experiencing what they thought might be an MI delayed calling for help for 4 to 5 hours. In an effort to avoid
the anxiety of a potentially devastating diagnosis and its implications, these patients came to premature closure and made potentially deleterious decisions about when to seek medical attention [17].

In a work environment, including the ICU, stressors (both work- and nonwork-related, both internal and external) affect each individual in a unique manner as mediated by a variety of factors. The interaction between stressors and mediating factors leads the individual to experience either strain or job satisfaction (Fig. 202.1) [18]. When this interaction leads to strain that is chronic or particularly intense (or both), burnout occurs.

Coined by the clinical psychologist Herbert Freudenberger [19] in 1974, burnout syndrome has been viewed as a behavioral or a psychological condition as well as a process or a syndrome [20]. Research during the past 2 decades (especially by Maslach and colleagues) has narrowed the current definition to encompass the spheres of emotional exhaustion, depersonalization (i.e., negative or cynical attitudes regarding work), and the absence of personal accomplishment—particularly among individuals who do “people work” (Table 202.1) [21]. While emotional exhaustion is the key component of the syndrome, people with all three symptoms experience the greatest degree of burnout [22]. Ultimately, this definition describes a process whereby highly motivated and committed individuals lose their spirit, their motivation for creativity, and, in the ICU, their belief in their ability to help people [23,24].

Burnout varies in intensity and duration, although it often has an insidious onset [25]. Even if an individual’s experience of burnout does not reach consciousness initially, it may affect others, burdening the system with another source of stress.

Many have argued that the cause of burnout lies in our need to believe that our lives are meaningful and that what we do is useful and important [23]. Work takes on a central role in providing some people with this sense of meaning in their lives. When individuals who derive such meaning from work think they have failed in their jobs, they may experience burnout. Burnout tends to afflict people who enter their professions with high motivation and idealism; it is particularly common in occupations often seen as “callings” [26]. In a supportive environment, highly motivated individuals reach their goals and achieve success, which leads to a sense of meaningfulness that itself increases the original motivation. However, in an unsupportive environment, these individuals cannot accomplish what they set out to do and consequently fail. For people who expect a sense of meaningfulness from work, such failure often leads to burnout.

Everyone experiences stress, but only those who start their careers with high levels of idealism, motivation, and commitment are at risk for burning out: “You cannot burn out unless you were ‘on fire’ initially” [23]. Burnout occurs almost exclusively in individuals who work with people, arising from the emotional stress that such interactions engender. ICU staff tend to be idealistic, committed, and driven—the very attributes which render them susceptible to burnout. In assessing and managing burnout, attention should be paid to the impact of job-related stressors and their ramifications, as well as the individual’s personality style. The character trait of hardiness (i.e., initiative, willingness to take risks, ability to face uncertainty,
and assertiveness in attaining and manipulating external rewards) has been shown to protect healthcare professionals (particularly nurses) from burnout in multiple stressful settings [27].

For the individual, burnout is characterized by physical, emotional, and attitudinal symptoms. Physical symptoms are nonspecific and include chronic fatigue, headaches, insomnia, weight changes, and worsening of chronic medical conditions. Burnout can lead to increased consumption of tobacco, alcohol, and illicit drugs. Emotional symptoms include despair, hopelessness, and depression. Relationships can become disrupted and the ability to work can be compromised [21].

On an organizational level, cynical attitudes toward work, colleagues, and patients can isolate coworkers and precipitate staff conflicts. At some hospitals, job dissatisfaction and burnout have led to absenteeism, accelerated staff turnover, and severe staff shortages, which may limit the number of ICU beds available for patient admissions [28].

Stress is a common aspect of medical practice for physicians, nurses, and trainees. Not surprisingly, studies over the past several decades have reported a high prevalence rate of burnout in healthcare professionals. Rates of burnout among physicians range from 25% to 60%, depending on working conditions and medical specialty [29,30,31,32,33,34]; burnout can develop at any stage of a physician’s career. Nurses also experience high levels of burnout. Studies in nurses indicate rates of 35% to 50%, depending on working conditions, clinical setting, and level of autonomy experienced [22]. Multiple factors have been associated with burnout in healthcare professionals, but the best characterized include: heavy workload, stressful work environments (e.g., ICUs), severity of patients’ illnesses, and conflicts with coworkers or patients [35,36].