The Critical Care Societies Call for Action about ICU Burnout Syndrome

Neil Orford on 06-07-2016

In the 1st July AJRCCM is a "call for action", asking us to recognise, understand, do something, about BOS. 

The article is summarised as follows;

Burnout syndrome (BOS) is a problem for high-stress professions - firefighters, police, teachers, health professionals. Intensive care, with the constant exposure to patients and families at the peak of their suffering, the constant and challenging daily work routines, resource issues, is an environment with a high risk of BOS (i.e. >50%), affecting the ability of our health professionals to care for themselves, and their patients. This “call to action” takes us through the history, definition, prevalence, risk factors, consequences, interventions. In summary;

What is BOS? 

A work-related constellation of symptoms and signs due to a mismatch between expectations of an individual about their position, and the actual reality of the position. It generally occurs in individuals without a history of mental health issues, and progresses gradually from mild symptoms - emotional stress, disillusionment, to negative attitudes, rio 3 classic symptoms;

1. Exhaustion 

2. Depersonalisation 

3. Reduced personal accomplishment. 

These manifest in various ways, lack of empathy, hopelessness, anger, insomnia, unprofessional behaviour, physical symptoms. There is overlap with other conditions;

1. Moral distress 

2. Perceived delivery of inappropriate care 

3. Compassion fatigue.

Prevalence of BOS 

25-33% critical care nurses have symptoms of severe BOS, up to 86% have one of the three classic symptoms - emotional exhaustion (73%), lack of personal accomplishment (60%), depersonalisation (48%). Their appears to be a unit effect, possibly reflecting culture. Up to 45% of critical care physicians report severe symptoms of BOS, up to 71% of paediatric critical care physicians. 

Risk factors

Most studies are cross-sectional, not longitudinal, making determination of temporal relationship between risk factors and BOS difficult to determine. However, they are divided into 4 categories;

1. Personal characteristics - self-critical, engage in unhelpful coping strategies, sleep deprivation, work-life imbalance. Also idealism, perfectionism, overcommitment. Personality types - less likely in extroverts, conscientious agreeable, more likely in “neurotic” individuals. It was thought o occur more in late career, but this appears to be wrong, with younger ICU nurses and doctors more likely to have BOS.

2. Organisational factors  - increasing workload, lack of control, insufficient rewards, general breakdown in the work community. 

3. Quality of working relationships - both inter professional and with patient-family

4. Exposure to end-of-life issues 


Health care professionals - PTSD, alcohol abuse, leaving work, suicidal ideation. 22-29% of ICU nurses report PTSD symptoms (intrusion, avoidance, negative alterations in cognitions and mood, and marked alterations in arousal and reactivity), with 98% of these having symptoms of BOS. Health systems - high turnover, decrease productivity, reduced overall quality of care, reduced ability to provide care due to carers leaving the profession. Patients - reduced quality of care, satisfaction, increased errors, higher mortality rates. 

How to stop or treat BOS

There are not large RCTs. Strategies focus on helping individuals to cope, and improving work environments. The American Association of Critical-Care Nurses recommend six standards to establish and sustain a healthy work environment: 

  1. skilled communication
  2. true collaboration
  3. effective decision-making
  4. appropriate staffing
  5. meaningful recognition
  6. authentic leadership. 

the authors add;

  1. conflict avoiding and managing
  2. improving end-of-life care

As individuals the authors suggest we should take responsibility for building resilience, a multidimensional characteristic that allows an individual to thrive when faced with complexity and high rates of change. How to build resilience;

  1. adequate self-care
  2. adequate rest
  3. spiritual practices
  4. exercise
  5. meditation
  6. hobbies outside of the work environment.

Additional strategies;

  1. setting limits
  2. work-life balance
  3. employing time management skills
  4. stress reduction measures 

Higher end strategies include;

  1. cognitive behavioural therapy
  2. support groups
  3. mindfulness training

The call for action

At the end the authors ask us to do something. To promote wellness in health-care providers as a vital part of good health-care. They suggest an approach that involves everyone;

  1. As individuals we recognise and manage our own BOS symptoms, and ask our family and friends to help us
  2. ICU unit-based leaders - strive to understand, prevent, treat BOS, to create explicit programs. 
  3. Hospital administrators 
  4. Funding agencies
  5. Professional Societies
  6. Academic institutions training the next generation
  7. Patient advocacy groups
  8. Policy makers 

Will we respond and protect ourselves and our colleagues? How? Do you monitor your own symptoms, your units symptoms?


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Alhof04 from United States Of America wrote 12-04-2016 07:23:13 am
As a new graduate nurse beginning my first position in a high pressure SICU, I have simultaneously been hired along with many other new graduate nurses. The unit has an extremely high turnover rate and a grueling, lengthy orientation process. Many preceptors seem to be forced into precepting, and the orientees are passed from teacher to teacher on a daily basis, adding to the stress of the learning experience. I can see how this creates a stressful situation for both newcomers and the nurses already working there. I have tried exercise, meditation, adequate sleep, etc., and it only seems to keep me just barely keep afloat. There seems to be a competitive, frustrated atmosphere in the unit. Fortunately, the quality of patient care remains in tact, with most patients eventually being discharged to a lower acuity floor. But it is a difficult environment to work in, the environment itself in terms of workers and teachers being far more challenging than the actual work itself. It seems as though no one has any confidence in my abilities, and almost expects me to screw up, even though I feel quite confident in my abilities to keep patients safe. It is very high pressure, and there is little to no encouragement. I think the burnout could be avoided in new nurses by not hiring so many at one time leading to a sense of competition, and also through encouragement and adequate support. Nursing school does not prepare new graduate nurses for a career in the ICU, so if the manager chooses to hire new grads, then a supportive and encouraging system should be set in place to facilitate a better teaching process, thereby reducing burnout.

FREOKUMAR from Australia wrote 12-12-2019 06:36:29 pm
I really appreciate author for blog on this very relevant topic!! BOS which is most likely multi factorial in its development, particularly in intensive care environment, being a result of many clinical interactions at rapid pace and also factors that can affect ICU staff in different ways, making it rather challenging to predict, assess, and treat.
When it comes to Solutions; they are not going to be one size fits all nor going to be straightforward.
However it's great to see that this topic is widely encouraged to be brought up and being addressed in non-judgmental manner!!




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