Burnout: A Closer Look at Integrative Medicine Strategies

Elaine Cheung, PhD; Ania Grimone, MS, LAc, CH, CPCC

The intensive care unit (ICU) is a busy, complex, and demanding work environment in which physicians, nurses, and other healthcare staff are routinely confronted with human suffering, patient morbidity and mortality, complex ethical decision-making, and difficult conversations with patients and their families. Professionals working in such high-stakes and high-stress environments are particularly vulnerable to developing burnout, a multidimensional response to chronic job-related stress, characterized by a low sense of personal accomplishment (e.g., loss of enthusiasm, fulfillment, zest, and creativity), emotional exhaustion (e.g., feeling overwhelmed, stressed, tired, lacking energy), and depersonalization (e.g., selfcriticism, doubting one’s self-worth, loss of confidence).1–3

Indeed, rates of burnout tend to be particularly high among healthcare professionals working in the ICU, with recent estimates suggesting that approximately half of critical care physicians and one-third of critical care nurses have burnout.4–10 Burnout is associated with increased rates of alcoholism, strained personal relationships, and poorer physical health in physicians.11–14 Beyond personal consequences for the individual, burnout has also been linked to poorer-quality patient care, including increased medical errors, and lower patient satisfaction with care.13,15,16 These findings highlight a need for early intervention and preventive efforts targeting burnout in medicine.17 This article highlights three approaches that critical care professionals can use to prevent and manage burnout in the ICU: 1) positive emotion coping skills, 2) acupuncture, and 3) herbal medicine.

Indeed, rates of burnout tend to be particularly high among healthcare professionals working in the ICU, with recent estimates suggesting that approximately half of critical care physicians and one-third of critical care nurses have burnout.

Positive Emotion Coping Skills
Many medical centers have begun offering wellness programs to address burnout among their staff.18,19 Most of these programs focus on targeting negative emotional constructs such as stress, depression, and anxiety (e.g., mindfulness-based stress reduction, cognitive behavioral stress management).18,19 However, a growing body of evidence suggests that positive emotion plays a uniquely important role in fueling resilient responses to stress.20–24 Moreover, positive emotion has been found to increase humanistic motivation in physicians and may help them derive greater meaning and professional satisfaction from their work.25–29

Our team at Northwestern University has developed a multicomponent, positive emotion coping skills program that targets increasing positive emotion as a pathway to reduce stress and burnout. This program involves providing a “toolbox” of eight empirically supported skills for increasing the frequency of positive emotion experienced in daily life: 1) positive reappraisal, 2) noticing positive events, 3) capitalizing on positive emotion, 4) gratitude, 5) mindfulness, 6) personal strengths, 7) self-compassion, and 8) compassion toward others. This theory-based program has demonstrated feasibility, acceptability, and preliminary efficacy for improving psychological adjustment across a number of groups experiencing high levels of life stress, including women with advanced cancer, people recently diagnosed with HIV, people with type 2 diabetes, and caregivers of patients with dementia.30–33 Recently we have tailored this program specifically to physicians and
medical trainees.

The positive emotion coping skills taught in this program may help address burnout in healthcare professionals through differentially targeting the three dimensions of burnout: low sense of personal accomplishment, emotional exhaustion, and depersonalization. Specifically, the skills of noticing positive events, capitalizing on positive emotion, gratitude, and compassion toward others can target a low sense of personal accomplishment lost enthusiasm) by training healthcare professionals to attune themselves toward the small, positive moments in medicine that can help them sustain a sense of meaning and satisfaction in their work. In addition, the skills of positive reappraisal and mindfulness can target emotional exhaustion (lost energy) by helping them cope more effectively with daily hassles and stressors, which can free up bandwidth to tackle larger goals and challenges. Finally, the skills of self-compassion and personal strengths can target depersonalization (loss of confidence) by helping them recognize their unique personal strengths during moments of stress or failure and to respond to these moments with compassion rather than self-criticism and perfectionism. These positive emotion coping skills can be easily infused into the busy lives of healthcare professionals working in the ICU. For instance, they can incorporate quick (one- to two-minute) mindful breathing exercises as they wash their hands throughout the day, or spend five minutes each evening reflecting on three good things that happened to them that day.

Acupuncture
Acupuncture involves stimulating strategic points of the body (“acupoints”) by inserting extremely thin, filiform needles into the skin. Acupuncture has been found to be an effective intervention for reducing stress and treating other conditions that are aggravated by chronic stress, such as fatigue, high blood pressure, irritable bowel syndrome, and sleep disturbance.34–38

Whereas a disadvantage of acupuncture is that it typically involves regular, repeated visits to a clinic, which may be difficult to integrate into healthcare professionals’ lives, acupressure is an allied intervention that, because it is self-administered and easily learned, does not require repeated visits to a clinic.39 Acupressure draws from the same principles as acupuncture, but involves applying manual pressure on relevant acupoints for a minimum of two minutes per point. One acupoint that is particularly relevant for stress reduction is HT7, located at the wrist crease on the radial side of the flexor carpi ulnaris tendon, between the ulna and the pisiform bones.

Another allied intervention that is easy to integrate into healthcare professionals’ lives is auricular acupuncture, which involves placing small magnets on specific acupoints of the auricle. The Shenmen acupoint, which is situated on each ear at the apex of the triangular fossa, is a common target for reducing stress. Auricle acupuncture on the Shenmen acupoint has been found to be helpful in calming the mind and alleviating stress, pain, anxiety, insomnia, and restlessness.3 Notably, auricle acupuncture has been found to reduce stress, anxiety, and burnout in healthcare providers.40

Herbal Medicine
Herbal medicine, including traditional Chinese adaptogenic herbs and formulas, may also be used to help people manage the physical manifestations of stress and burnout. Herbal supplements that have been found to be beneficial for reducing stress and fatigue include ginseng (Panax ginseng), eleuthero (Siberian) ginseng (Eleutherococcus senticosus), holy basil (Ocimum tenuiflorum), astragalus root (Astragalus membranaceus), schisandra (Schisandra chinensis), licorice root (Glycyrrhiza glabra), rhodiola (Rhodiola rosea) and mushrooms such as Cordyceps, reishi, shiitake, and maitake.41–45 Although these herbal supplements can be obtained over the counter without a prescription, it is important to be mindful of the potential adverse side effects and interactive effects that these supplements may have with prescription medications. We recommend consulting an herbalist before initiation of herbal supplements.

Summary
Three approaches that critical care professionals may use to prevent and manage burnout in the ICU are: 1) positive emotion coping skills, 2) acupuncture, and 3) herbal medicine. These quick, convenient, and relatively inexpensive strategies can easily be integrated into the busy lives of healthcare professionals and may help people cope more effectively with the stress of working in the ICU. 

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