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The Critical Nature of Addressing Burnout Prevention: Results From the Critical Care Societies Collaborative's National Summit and Survey on Prevention and Management of Burnout in the ICU

Kleinpell, Ruth PhD, RN, ACNP, FCCM1,2; Moss, Marc MD, FCCP3,4; Good, Vicki S. DNP, RN, CPPS5,6; Gozal, David MD, MBA, ATSF7,4; Sessler, Curtis N. MD, FCCP, FCCM, ATSF8,9

Author Information
doi: 10.1097/CCM.0000000000003964

Abstract

The increasing awareness and interest in burnout syndrome (BOS) among healthcare providers is raising a surge of initiatives promoting clinician wellness, and aiming at better understanding the importance of detecting, addressing, mitigating, and preventing burnout.

Among some of the salient initiatives that have been launched to address burnout and promote resilience, we should point out those of the National Academy of Medicine (NAM), American Medical Association (AMA), American Nurses Association (ANA), and Accreditation Council for Graduate Medical Education (ACGME) (1–4). These programs clearly show that a national conversation has been started, with the ultimate goal of addressing burnout in healthcare professionals and emphasize the unique concerns among professional organizations on the toll that burnout is imposing on healthcare workers and their patients.

BURNOUT IN CRITICAL CARE HEALTHCARE CLINICIANS

The consequences of clinician burnout are significant, with implications for workplace morale, patient safety, quality of care, and costs of care, including costs related to clinician turnover (5). While research has substantiated that all healthcare providers are at risk for burnout, critical care clinicians are at particularly heightened risk. Indeed, recent surveys indicate that intensivists exhibit the highest rate of burnout among all specialties (6), and critical care nurses have also been shown to have elevated rates of burnout (7–9). Notwithstanding the pervasive nature of burnout among all types of healthcare professionals, important differences exist in critical care workers. In addition to the elevated rates of burnout among intensive care unit (ICU) clinicians, the triggers of burnout in the ICU are unique, and relate to exposure to pain, death and dying, open wounds, trauma and tragedy, and the perception of delivering inappropriate or insufficient care (7).

However, there is no single and readily identifiable cause of burnout; rather, many factors can contribute to it, such that the determinants of burnout in any given clinical provider are multiple and diverse, and usually very personalized. Nonetheless, a recent perspective highlighted that the increasing clerical burden, due in part to electronic medical record documentation requirements, is one of the largest drivers of burnout in healthcare (10). Furthermore, the unique characteristics of working in the ICU exposes clinicians to inordinately high levels of stress, intra- and interpersonal conflicts regarding goals of care, and moral distress from providing care to patients at high risk of death. These factors both separately and together lead to increased risk of burnout and foster potentially unique opportunities to mitigate such enhanced risk, by directly and interactively addressing the particular clusters of precipitating factors that emerge in the ICU.

CRITICAL CARE SOCIETIES COLLABORATIVE

The Critical Care Societies Collaborative (CCSC) comprises the four major critical care-focused U.S. professional and scientific societies, which are the American Association of Critical-Care Nurses (AACN), American Thoracic Society (ATS), American College of Chest Physicians (CHEST), and Society of Critical Care Medicine (SCCM). The CCSC, recognizing the importance of addressing BOS among critical care professionals, published a call for action in 2016 that reviewed relevant research and addressed potential interventions for mitigating burnout (11). Highlighted in the call for action was recognition that the ICU environment poses challenges to clinicians because of the nature of critical illness and because organizational and individual risk factors can result in moral distress, compassion fatigue, and psychologic distress, which can lead to BOS. In a coordinated effort to further promote the dissemination of awareness and gauge membership feedback, the CCSC has also sponsored symposia at its member organizations' national meetings, including AACN's National Teaching Institute & Critical Care Exposition, SCCM's Annual Congress, and the CHEST Annual Meeting, and ATS International Conference. The CCSC has also developed information on BOS, which can be found on its website, and has promoted social media conversations, including the use of the hashtag #stopICU burnout.

NATIONAL SUMMIT ON PREVENTION AND MANAGEMENT OF BURNOUT IN THE ICU

Building on the call for action, the CCSC sponsored the National Summit on Prevention and Management of Burnout in the ICU in December 2017, and invited 55 experts from various fields, including psychology, sociology, employee assistance, integrative medicine, psychiatry, suicide prevention, occupational medicine, nursing, social work, sleep medicine, bereavement support, ethics, palliative care, meditation, mindfulness-based stress reduction, and research (12). Former ICU patients and graduate psychology, pharmacy, and nursing students also attended to offer diverse viewpoints and expertise and to formulate approaches that accelerate actions to address and prevent BOS. A number of national organizations were represented, including the American Hospital Association, National Patient Safety Foundation, the Joint Commission, ACGME, American Foundation for Suicide Prevention, NAM, the Institute for Healthcare Improvement, and Shambhala Meditation Center. The goals of the summit were to focus on identification, risk factors, and interventions for prevention and mitigation of burnout, as well as areas important to developing a research agenda as it pertains to critical care healthcare professionals.

Attendees joined one of five breakout groups, which focused on: 1) factors influencing burnout in 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. Attendees were unanimous in their identification of BOS as a recognized and imminent risk that is embedded in the fabric of critical care work. Therefore, targeting measures to address the stressful ICU environment was acknowledged as a key and priority component in mitigating burnout in ICU clinicians. A number of thematic concepts, both distinct and overlapping, emerged from the breakout group discussions, as outlined in Supplemental Tables 1–5 (Supplemental Digital Content 1, http://links.lww.com/CCM/E884).

TABLE 1.
TABLE 1.:
Institutional Resources and Measures Being Implemented

Summit attendees discussed the value of various interventions and the role of organizations in promoting healthy work environments. Discussants determined that both organizational and individual accountability are needed to effectively mitigate BOS. Although they acknowledged greater awareness of the need to build resilience and promote healthy work environments, additional resources are needed to aid clinical application. Areas for additional research with implications for ICU clinicians were also identified, including measures to identify and quantify risks for burnout, and the impact of targeted interventions.

NATIONAL SURVEY ON MEASURES TO MITIGATE BURNOUT AND PROMOTE RESILIENCY

As an extension of the National Summit work, a survey was disseminated to the members of the CCSC organizations via blast email and newsletter notifications between September to December 2018. Research Electronic Data Capture (project-redcap.org) was used to collect the data with an anonymous survey link. The survey received exempt IRB review status, and consisted of six questions assessing what resources and measures were being implemented at the organizational and unit level including the presence of a wellness committee, chief wellness officer or similar role, and the level of importance that the employing institution placed on promoting wellness and mitigating burnout.

Responses were received from 680 critical care clinicians including 288 physicians (42.4%), 296 nurses (43.6%), 35 pharmacists (5.2%), 43 advanced practice registered nurses (6.3%), 10 physician assistants (1.5%), and 14 others (21%), including respiratory therapists, dieticians, and ICU nurse administrators. Some reported having a wellness committee (n = 287, 42.3%), or a chief wellness officer or an individual assigned to a similar organizational role (n = 156, 23.2%). A number of organizational resources were reported including healthy food choices on campus (n = 331, 55.8%), on-campus exercise/gym facilities (n = 264, 44.5%), self-scheduling (n = 258, 43.5%), interpersonal/communication training (n = 131, 22.1%), ability to take personal/respite days (n = 148, 25%), mindfulness based stress reduction classes (n = 107, 18.0%) and staff support groups (n = 66, 11.1%), among others (Table 1).

The perceived level of importance placed on promoting wellness and mitigating burnout varied among respondents, with 10.9% (n = 74) reporting “highly important”, 31.7% (n = 215) reporting “important,” 38.9% (n = 264) reporting “not important,” and 18.6% (n = 126) reporting “not at all important.”

In response to open ended questions inquiring about additional organizational or personal strategies to promote wellness and resiliency, a number of practices were reported including taking vacation time, unit-based celebrations of holidays, debriefing sessions after deaths or other difficult situations, use of a unit-based recognition and retention committee, and employee appreciation activities, among others.

Other comments highlighted the importance of making organizational changes to promote a healthier work environment. One respondent identified “Despite all of the wellness options, what matters most is not overworking ICU clinicians. Scheduling too many consecutive ICU weeks or nights will lead to burnout, regardless of how many “wellness events” are offered.” Another related “The majority of these projects seem to stress individual wellness and ignore the environment we work in. This is outright dangerous. There needs to be a balance of individual wellness as well as creation of an actual work environment (work hours, call, pay, autonomy) that doesn’t lead many to burnout”. Another shared “This is a highly important topic. I think many of my coworkers are burned out. The major cause of burnout is due to the hospital administration not caring about improving working conditions for clinicians.” Another shared “It is a system issue and not something that you can exercise or meditate your way out of.”

Other comments reinforce the need for disseminating information on strategies for promoting a healthy work environment in clinical practice. One respondent shared “Burnout is a topic raised at many hospital and ICU meetings, but no real movement is being implemented to resolve the issues or improve quality of life for ICU providers”. Another shared “This is very important but there is not enough institutional awareness. My large corporate healthcare institution is not even close to addressing wellness and burnout”. Another shared “Our profession is not doing enough to mitigate burnout. I struggle with this. I’ve worked in three different ICUs and none offer anything in terms of burnout or retention.” Another cited “It is a critical topic that is ineffectively addressed at this point. Even though I think that the topic of burnout is being talked about more, I do not feel that there are adequate resources on how to prevent or address it.”

Others identified that little to no measures were being implemented within their organizations. One respondent related “A ‘how to’ resource would be so useful. This is by far the most important issue in critical care medicine.”

DISCUSSION

The National Summit provided insights from experts in the field regarding 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 further explore practical strategies to address, mitigate, and prevent burnout. Research has established that organizational interventions, including appropriate staffing, meaningful recognition, team building, or altering work schedules, and individual interventions, including stress reduction training, relaxation techniques, exercise, meditation, healthy eating, and sleep hygiene measures, can reduce the risk of burnout (13, 14). However, additional information is needed on which strategies are most useful for critical care clinicians and whether a more specifically tailored or personalized approach is necessary to achieve optimal results.

The results of the national survey from a subset of critical care clinicians identified that a number of initiatives are being implemented both at the hospital and unit levels to promote wellness and address the prevention of burnout. Although the sample size represents a small portion of the CCSC membership, the responses acknowledge the importance of addressing prevention measures, and of proactively identifying unit based and organizational initiatives. Comments reflect the importance of addressing organizational issues, and not solely focusing on clinician-based measures. While some respondents identify the current use of measures such as promoting healthy eating, exercise and self-care measures including taking vacation or respite time, others promote restructuring of the current workflow in the ICU by advocating for flexible and self-scheduling, ICU team building, limiting the maximum number of days to work consecutively in the ICU, and enabling respite days.

Clinicians identified that both individual and organizational measures were being implemented, however, majority (57%) perceived that the level of importance placed on promoting wellness and mitigating burnout was not important at the organizational level. Some respondents report that no measures are being used within their organizations, and that colleagues are experiencing burnout. Dissemination and application of strategies to address burnout in critical care clinicians and promote a healthy work environment are needed.

Recently published reports on efforts to reduce burnout and promote engagement have demonstrated that deliberate, sustained, and comprehensive efforts by organizations can make a difference (15). Because a number of factors affect clinician well-being and resilience, both organizational and individual interventions bring value to managing work-related stress, improving well-being, and alleviating fatigue and moral distress (16). The national attention that is being focused on addressing workplace environments as well as resources for building clinician resilience by entities such as NAM's Clinician Well-being Knowledge Hub (17), AMA's Steps Forward module on reducing burnout (18), ANA's Healthy Nurse Healthy Nation grand challenge (3), and AACN's Healthy Work Environment standards (19) showcase broad-based support. In today's challenging healthcare environment, there is a strong business case to be made for organizations and individuals to invest in efforts to reduce burnout and promote engagement (15).

IMPLICATIONS

Based on the summit and national survey, the CCSC will continue to raise awareness, disseminate information to critical care clinicians and key stakeholders, advocate for workplace changes to promote healthy work environments, and promote research to further explore practical strategies to address, mitigate, and prevent BOS. A number of resources from the summit are now available on the CCSC website (12). The CCSC also plans to launch a call for research on the prevention and mitigation of burnout among critical care professionals. NAM's ongoing work to address clinician well-being and resilience highlights the critical role that organizations, including professional societies, can play in promoting awareness, recognition, and management of burnout for healthcare clinicians (20,21). NAM plans to expand its recently launched resource website (22) as one way to promote awareness. Promoting use of this resource and others is another important role that the CCSC can play.

Because ICU care revolves around life-threatening critical illness, addressing the prevention of burnout in the ICU has also become critical. The CCSC member organizations will continue to push for improved awareness of BOS among their members, disseminate knowledge, and facilitate access to individual and organizational tools to promote recognition of BOS. The CCSC will also continue to address the prevention, identification, and mitigation of burnout in ICU healthcare professionals. The future of the profession and optimal patient care depend on it.

ACKNOWLEDGMENTS

This article reports on the work of a Critical Care Societies Collaborative (CCSC) workgroup. The CCSC comprises the four major U.S. professional and scientific societies dedicated to the care of critically ill patients, which are the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine.

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      Keywords:

      burnout; clinician well-being; critical care; intensive care unit; resilience

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