BOS Characteristics. The emergence of BOS in the context of cultural developments that took place during the transformation from an industrial society into a service economy has been elegantly discussed.7 Burnout traditionally includes the elements of emotional exhaustion, depersonalization, and reduced personal accomplishments.1 BOS not only adversely affects critical care providers’ mental health and sense of well-being but impairs their performance as well. As such, BOS is a recognized threat to the quality and safety of patient care.8–10 Interestingly, traits valued by healthcare professionals such as compassion, altruism, and perfectionism may actually predispose them to BOS when they are pushed to mental or physical
extremes.11 Among physicians, BOS is associated with increased job dissatisfaction, shorter employment tenure, greater numbers of medical errors, negative attitudes toward patients, patient dissatisfaction, more failed relationships, depression, alcohol abuse, suicidal ideation, and posttraumatic stress disorder.11,12 Closely associated with BOS, moral distress, delivery of inappropriate care, and compassion fatigue all commonly occur among critical care healthcare professionals.
In addition, BOS generates a significant financial drain on the healthcare system because of its association with absenteeism, employee turnover, and early retirement.13 For example, the annual rate of intensive care unit (ICU) nursing turnover has been reported to range from 13% to 20%.14 The cost of replacing an ICU nurse currently approaches $100K, and replacing an ICU physician at least 2.5 times that. Accordingly BOS represents a major line item for any hospital budget,15 and reduction in turnover represents an appropriate quality metric for any ICU.
BOS Risk Factors. Risk factors associated with BOS among critical care professionals can be categorized as: 1) personal characteristics, 2) organizational factors, 3) quality of working relationships, and 4) exposure to end of-life issues.16 At-risk personal characteristics include self-criticism, perfectionism, inadequate coping strategies, sleep deprivation, and work-life imbalance.17 In terms of the influence of organizational factors, healthcare BOS has been described as a byproduct of the culture of medicine, which includes self-denial, persistence, and expected consistent, expert performance under adverse conditions.18,19 Frequent participation in end-of-life care is common among critical care practitioners and has been specifically called out as a risk factor for BOS.20
BOS and the Critical Care Societies Collaborative. Although BOS can occur in any profession, risk is especially high for critical care practitioners
who daily are challenged by high levels of stress in a frequently hostile environment.21 In recognition of this destructive critical care epidemic, the Critical Care Societies Collaborative (CCSC) began a focus on BOS in 2014 and published a call for action in 2016 to raise awareness of BOS, in particular its diagnostic criteria, prevalence, causative factors, and consequences.5 More recently, a Burnout Summit, organized by the CCSC,
was convened on the campus of Northern Illinois University in December 2017. Experts from multiple professions discussed BOS among ICU professionals with a focus on its identification, influential factors, the value of organizational and individual interventions, and development of an ICU BOS research agenda. An important conclusion of the summit was that harnessing “stress energy” is associated with the provision of intensive care in a positive fashion to transition the paradigm of human doing to human being.
BOS Treatment Options
Systems/Processes. Systems approach methods that focus on the mismatch between the individual and the work environment must provide the foundation for the solution to BOS.22 While it is important to maximize resilience and ensure recognition and treatment for colleagues with BOS, identification and eradication of its root causes should be the priority. Full engagement of the entire multiprofessional team is not only good for the patient, it is essential for the health of the team members. This multidisciplinary approach is built around connections that include meaningful interactions and ongoing personal and professional development of the entire care team.23 Needless and avoidable fragmentation in the absence of multidisciplinary collaboration facilitates unnecessarily contentious care.24 Measures to improve communication among critical care professionals can result in reduced conflict and enhanced relationships.25 Another important strategy to minimize contention is the development of clinical standards, based on evidence when available and group consensus when evidence is lacking. From a systems/process point of view, both environmental and individual-focused strategies can result in clinically meaningful reductions in burnout among critical care providers.26
Environment. Identifying and eliminating frustrations in the physical workplace may come with expense, but such cost is likely trivial compared to the personnel expense created by BOS turnover. For example, the electronic medical record and the burden of documentation, frequently viewed as non-value-added activities, remain important associations with BOS among healthcare providers.27 Specific foci within the environment that affect BOS and that are amenable to intervention include high psychological demands, low job control, and low supervisor social support.28 The importance of a supportive work environment for the success of interventions designed to alleviate or prevent BOS has been emphasized.29 It is intuitive that adequate staffing decreases the risk of emotional exhaustion as an antecedent for BOS.30
People. Trainees in critical care medicine need to be aware of not only the multiple rewards associated with the practice of intensive care, but also the significant daily stresses associated with it. Developing readiness, plasticity, and resilience31 within the intensive care environment must assume the same importance as preparation for board certification and licensing. These efforts include teaching self-awareness and mindfulness.32 Hand-holding later in a critical care practice career is likely to be futile.24 Resiliency is a multidimensional characteristic that allows an individual to thrive in the setting of stress—the foundation of resiliency is self-care in terms of active promotion of wellness.33,34 Multiple reports suggest the benefit of regular exercise in preventing BOS.35 Just as lack of quality sleep is a risk factor for transition to delirium among critically ill patients, lack of sleep among health care professionals represents a modifiable underpinning for BOS. From this perspective, quality sleep represents a risk management issue for everyone in the ICU.
In closing, for this first 2018 issue of Critical Connections, with the real threat of BOS for all critical care practitioners, it is appropriate to consider the wise words of Thich Nhat Hanh, a Zen Buddhist minister and peace activist: “Until we are able to love and take care of ourselves, we cannot be of much help to others.”
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