Medical Technology

Burnout: ICU Staff Not Aware Despite Evidence

Many critical care providers appear to be unaware that they are burned out from their role in pandemic care. Objective measures show that they are experiencing high levels of burnout in all its manifestations, even if they don’t recognize it themselves. 

“I think that ignoring or under-recognizing any medical or mental health condition is extremely dangerous,” Anuj Mehta, MD, Denver Health & Hospital Association, Denver, Colorado, told Medscape Medical News in an email. “Denying or not recognizing that one has high blood pressure or diabetes does not stop the complications from arising and burnout is a similar situation: When practitioners are burnt out, they suffer severe mental and physical health consequences, increased job turnover, and worsening patient outcomes. And this will happen regardless of whether they have ‘insight’ into their burnout,” she added.

“So, the first step in addressing a problem is acknowledging that a problem exists: Burnout is not a natural forgone conclusion of critical care medicine or healthcare in general, and we should not accept it,” Mehta reemphasized. For this reason, Mehta and colleagues performed a multicenter study to assess burnout in critical care providers.

The study was published online December 7, 2021, in Chest.

Three Diverse ICUs

A total of 58 providers working in ICUs at three diverse hospitals in Denver, Colorado, participated in the study. This included 26 physicians, 22 nurses, six respiratory therapists (RTs), three pharmacists, and one case manager. All participants responded to questions on the Maslach Burnout Inventory (MBI) and interviews and focus groups were conducted either in person or virtually, according to the authors.

Most of the participants (61%) were women; about the same percentage were married, and almost half had worked in their current ICU for less than 5 years. “All practitioner types had moderate to high rates of individual MBI components,” Mehta and colleagues reported. For example, 71.4% of participants had moderate to high levels of emotional exhaustion on the MBI.

Some 53.6% of participants reported having feelings of depersonalization on the same inventory with the same percentage reporting that they felt a lack of personal achievement. However, results varied depending on whether the participant was a nurse or a physician.

Nineteen out of 22 nurse participants, for example, reported higher levels of emotional exhaustion while 15 of them reported feelings of depersonalization. Nurses also registered lower levels of personal achievement compared with other practitioner types, especially physicians. Compared against physicians, nurses had an over ninefold risk of reporting lower levels of personal achievement at an adjusted odds ratio (AOR) of 9.38 (95% CI, 2.21-39.82).

A lack of respect reported by participants correlated with low levels of personal achievement. “When directly asked to rate their burnout, few participants reported moderate to high levels of burnout,” Mehta and colleagues stressed. As they speculate, self-reported levels of burnout may simply reflect the fact that ICU practitioners are unwilling to admit the extent of their own burnout due to stigma.

Three Drivers

Based on analyses of the qualitative interviews, three drivers of burnout emerged, the first being patient factors.

“Participants highlighted medically ‘futile’ cases and difficult families as the primary patient factors driving burnout,” the authors elaborate. It wasn’t that participants did not want to care for sick patients — they signed up for exactly this role, as participant feedback suggested.

However, performing what providers perceived as being a medically futile task was not the same thing as caring for sick patients, and “aggressive interventions for patients with little chance of recovery was often viewed as contributing to ‘patient suffering’ and drove burnout among all participants,” as Mehta observed.

A second driver of burnout was what the authors termed “team dynamics.” By this they meant that at least some physicians withdrew from discussing goals of care with patients and their families when a patient’s recovery became less likely. Abdicating their responsibility to take part in difficult end-of-life conversations created animosity within the team and directly contributed to their burnout, as the authors point out.

Nurses and RTs also felt that physicians ignored their experience in caring for patients and the knowledge this experience provided them. Physicians, in turn, also expressed frustration by a lack of trust from some of the nurses. An indifferent hospital culture that overwhelmed practitioners with administrative duties also drove burnout across all practitioner types, the authors continued.

“Given limited amounts of time, the increased administrative tasks inevitably came at the expense of patient care and made it seem that the hospital/institution was motivated primarily by finances,” researchers state. Electronic medical records (EMRs) were also singled out, at least by nurses, as contributing to their own burnout. This was because EMRs allowed physicians to enter orders from wherever they happened to be, again reducing time at the bedside helping in discussions with patients.

Participants were also critical of hospital leadership, where they felt that leadership was more prone to point out errors than to recognize how difficult it is to treat medically complex patients.

Alleviating Burnout?

Based on these findings, several strategies might help alleviate burnout among critical care practitioners, the authors suggested. First, some studies have proposed that individuals with greater resiliency may be less prone to burnout. Thus, “our findings would suggest that promoting resiliency [in practitioners] focused on caring for patients with little chance for recovery may have a broader impact at reducing burnout in the ICU,” researchers suggest.

Offering more routine palliative consultations or taking a multidisciplinary approach to having discussions about the goals of care may also help address patient and team-level factors that drive burnout, they added. On the other hand, interventions that focus on only one practitioner type and that don’t take into consideration the “contagious” nature of team-based dynamics are likely to be ineffective in ICUs, the authors cautioned.

Instead, “we speculate that it may be more effective for health systems to focus interventions on improving team dynamics and hospital culture,” Mehta and colleagues suggested. Indeed, they speculated that interventions that ignore hospital culture will have little success in helping relieve the burnout burden among its critical care practitioners.

“With reports of nearly 30% of HCWs (healthcare workers) considering leaving the field due to burnout, healthcare finds itself at the precipice of another catastrophe [and] urgent action is needed to develop effective and sustainable interventions to reduce burnout in healthcare, including the ICU,” the authors advise.

Asked if being unaware of how burned out an ICU provider might be could be a good thing, Robert Maunder, MD, deputy psychiatrist-in-chief and head of psychiatry research and professor of psychiatry, University of Toronto, Toronto, Ontario, Canada, noted that denying or underestimating the impact of chronic stress is a common response and may be adaptive to some extent in settings like the ICU, but in the long run, improving conditions that are contributing to occupational harm depend on acknowledging the harm.

“It isn’t good for patients or the staff for the professionals providing care to be burnt out,” he stressed in an email to Medscape Medical News. Maunder also felt it is “critical” for institutions to recognize that they control the factors that contribute the most to burnout. “Putting the onus on individuals to be more resilient isn’t sustainable and it doesn’t fit with the evidence,” he said. Completely eliminating burnout is unlikely, Maunder conceded.

“But we could do much better,” he said. “These staff were affected by the moral distress of providing care in the face of futility and dealing with challenging family dynamics,” Maunder added.

Burnout Has Costs

“These are challenges that we can respond to as a system,” he insisted. Mehta agreed with Maunder, adding that frankly, burnout is expensive. “The long-term costs of replacing physicians, nurses, and respiratory therapists in the ICU are staggering, and constantly replacing people who are leaving reduces morale and leads to far less experienced people providing care,” she explained.

Burnout also affects patient safety and outcomes, which can affect reimbursement, malpractice claims, and hospital rankings, Mehta noted. “In order to see the benefits of doing everything to tackle burnout, hospitals have to shift their mindset from the short term to the long term, she suggested.

“In order to accomplish this, hospitals and health systems have to stop thinking of practitioners as replaceable or cogs in the system and recognize that healthcare workers are their most valuable resource that should be protected above all else,” Mehta said.

The study was funded in part by the National Institutes of Health.

Mehta and Maunder declared no conflicts of interest.

Chest. Published online December 7, 2021.

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