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Epstein EG, Haizlip J, Liaschenko J, Zhao D, Bennett R, Marshall MF. Moral Distress, Mattering, and Secondary Traumatic Stress in Provider Burnout: A Call for Moral Community. AACN Adv Crit Care 2021; 31:146-157. [PMID: 32525997 DOI: 10.4037/aacnacc2020285] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Burnout incurs significant costs to health care organizations and professionals. Mattering, moral distress, and secondary traumatic stress are personal experiences linked to burnout and are byproducts of the organizations in which we work. This article conceptualizes health care organizations as moral communities-groups of people united by a common moral purpose to promote the well-being of others. We argue that health care organizations have a fundamental obligation to mitigate and prevent the costs of caring (eg, moral distress, secondary traumatic stress) and to foster a sense of mattering. Well-functioning moral communities have strong support systems, inclusivity, fairness, open communication, and collaboration and are able to protect their members. In this article, we address mattering, moral distress, and secondary traumatic stress as they relate to burnout. We conclude that leaders of moral communities are responsible for implementing systemic changes that foster mattering among its members and attend to the problems that cause moral distress and burnout.
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Affiliation(s)
- Elizabeth G Epstein
- Elizabeth G. Epstein is Associate Professor and Department Chair, University of Virginia School of Nursing; and Associate Professor, School of Medicine Center for Health Humanities and Ethics, 202 Jeanette Lancaster Way, Charlottesville, VA 22903
| | - Julie Haizlip
- Julie Haizlip is Clinical Professor of Nursing and Associate Professor of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Joan Liaschenko
- Joan Liaschenko is Professor, University of Minnesota Center for Bioethics and School of Nursing, Minneapolis, Minnesota
| | - David Zhao
- David Zhao is an undergraduate student at the University of Chicago, Chicago, Illinois
| | - Rachel Bennett
- Rachel Bennett is a doctoral student at University of Virginia School of Nursing, Charlottesville, Virginia
| | - Mary Faith Marshall
- Mary Faith Marshall is Emily Davie and Joseph S. Kornfeld Professor of Biomedical Ethics, University of Virginia School of Medicine Center for Health Humanities and Ethics; and Professor of Nursing, University of Virginia School of Nursing, Charlottesville, Virginia
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Intensive Care Unit Nurse: Could We Call a Palliative Care Consult? Intensive Care Unit Provider: It's Too Early. Palliative Care Integration in the Intensive Care Unit: The Struggle to Translate Evidence Into Practice. Dimens Crit Care Nurs 2021; 40:51-58. [PMID: 33560635 DOI: 10.1097/dcc.0000000000000451] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Despite evidence regarding the value of palliative care, there remains a translation-to-practice gap in the intensive care setting. The purpose of this article is to describe challenges and propose solutions to palliative care integration through the presentation and discussion of a critical care patient scenario. We also present recommendations for a collaborative palliative care practice framework that holds the potential to improve quality of life for patients and families. Collaborative palliative care is characterized by close working relationships with families, interprofessional intensive care unit healthcare teams, and palliative care specialists. The shortage of palliative care specialists has become a pressing policy and practice issue and highlights the importance of increasing primary palliative care delivery by the intensive care team. Underexplored aspects of collaborative palliative care delivery include the interprofessional communication required, identification of key skills, and expected outcomes. Increased recognition of intensive care unit palliative care as a process of engagement among nurses, providers, patients, and their family members heralds a vital culture shift toward collaborative palliative care. The interprofessional palliative specialist team has the expertise to support intensive care teams in developing their primary palliative skills and recognizing when specialist palliative care support is required. Promotion of strategic palliative care delivery through this collaborative framework has the potential to decrease suffering among patients and families and reduce moral distress among healthcare professionals.
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Where to Look for a Remedy? Burnout Syndrome and its Associations with Coping and Job Satisfaction in Critical Care Nurses-A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18084390. [PMID: 33924271 PMCID: PMC8074906 DOI: 10.3390/ijerph18084390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/13/2021] [Accepted: 04/17/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Burnout is a psychological, work-related syndrome associated with long-term exposure to emotional and interpersonal stressors in the workplace. Burnout syndrome in nurses is often caused by an imbalance between work requirements and preparation and fitness for work, a lack of control, insufficient performance recognition and a prolonged exposure to stress. AIM The aims of this study were to explore the associations between levels of burnout syndrome, coping mechanisms and job satisfaction in critical care nurses in multivariate modelling process. A specific aim was also to explore whether coping and job satisfaction in critical care nurses are gender related. METHODS A cross-sectional multicentre study was conducted in a convenience sample of 620 critical care nurses from five university hospitals in Croatia in 2017. The data were collected using the Maslach Burnout Inventory and the Ways of Coping and Job Satisfaction Scale together with the nurses' demographic profiles and were analysed using a multivariable model. RESULTS The results showed no significant association between gender, coping mechanisms and job satisfaction. However, significant negative associations between burnout and job satisfaction (OR = 0.01, 95%CI = 0.00-0.02, p < 0.001) and positive association between burnout and passive coping (OR = 9.93, 95%CI = 4.01-24.61, p < 0.001) were found. CONCLUSION The association between job satisfaction and burnout in nurses urges hospital management teams to consider actions focused on job satisfaction, probably modifications of the work environment. Given that passive coping may increase the incidence of burnout, it is recommendable for active coping to be implemented in nurses' training programmes as an essential element of capacity building aimed at reducing the incidence of burnout in nurses.
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Garros D, Austin W, Dodek P. How Can I Survive This?: Coping During Coronavirus Disease 2019 Pandemic. Chest 2021; 159:1484-1492. [PMID: 33220296 PMCID: PMC7672336 DOI: 10.1016/j.chest.2020.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 11/16/2022] Open
Abstract
Worldwide, health-care professionals are experiencing unprecedented stress related to the coronavirus disease 2019 pandemic. Responding to a new virus for which there is no effective treatment yet and no vaccine is beyond challenging. Moral distress, which is experienced when clinicians are unable to act in the way that they believe they should, is often experienced when they are dealing with end-of-life care issues and insufficient resources. Both factors have been widespread during this pandemic, particularly when patients are dying alone and there is a lack of personal protection equipment that plagues many overburdened health-care systems. We explore here, guided by evidence, the concept and features of moral distress and individual resilience. Mitigation strategies involve individual and institutional responsibilities; the importance of solidarity, peer support, psychological first aid, and gratitude are highlighted.
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Affiliation(s)
- Daniel Garros
- Department of Pediatrics, John Dossetor Health Ethics Centre, University of Alberta, Edmonton, Alberta, Canada.
| | - Wendy Austin
- Division of Critical Care, and the Faculty of Nursing, John Dossetor Health Ethics Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Peter Dodek
- Critical Care Working Group, Center for Health Evaluation and Outcome Sciences, Edmonton, Alberta, Canada
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Ball AM, Schultheis J, Lee HJ, Bush PW. Evidence of burnout in critical care pharmacists. Am J Health Syst Pharm 2021; 77:790-796. [PMID: 32280966 DOI: 10.1093/ajhp/zxaa043] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Studies of critical care physicians and nursing personnel indicate a potentially high rate of burnout. To date there is a paucity of data in critical care pharmacists assessing burnout in this group. The purpose of this study was to assess the incidence of risk of burnout in critical care pharmacists. METHODS Critical care pharmacists were solicited via email to complete an anonymous, electronic questionnaire regarding burnout. Subject demographic and employment characteristics were collected along with the validated, 22-item Maslach Burnout Inventory Health Services Survey in the study cohort. Burnout was assessed from 3 aspects, emotional exhaustion, depersonalization, and lack of personal accomplishment. High degree of burnout was defined as a score >27 in emotional exhaustion, or score >10 in depersonalization, or score <33 in personal achievement. Risk factors of burnout were evaluated using descriptive statistics and logistic regression. RESULTS Out of 3,140 critical care pharmacists, 193 (6.1%) completed surveys. The mean scores were 25.3, 7.5, and 36.7 for emotional exhaustion, depersonalization, and reduced personal achievement, respectively. Overall, 123 pharmacists (64%) reported at least one syndrome of burnout, and 28 pharmacists (14.5%) reported burnout in all 3 scales. No single risk factor was identified to be associated with the risk of burnout. CONCLUSION Risk of burnout is high in critical care pharmacists, at 64%, and is comparable to the risk in other critical care practitioner groups. This emphasizes the importance of continuing to evaluate risk factors for burnout and providing resources for burnout prevention to high-risk practitioners.
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Affiliation(s)
- Amanda M Ball
- Department of Pharmacy, Duke University Hospital, Durham, NC
| | | | - Hui-Jie Lee
- Duke CTSI Biostatistics, Epidemiology and Research Design (BERD) Methods Core, Duke University, Durham, NC
| | - Paul W Bush
- Department of Pharmacy, Duke University Hospital, Durham, NC
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Peng X, Meng X, Li L, Hu C, Liu W, Liu Z, Ma X, Xu D, Xing Z, Zhu Z, Liu B, Zhang L, Peng M. Depressive and Anxiety Symptoms of Healthcare Workers in Intensive Care Unit Under the COVID-19 Epidemic: An Online Cross-Sectional Study in China. Front Public Health 2021; 9:603273. [PMID: 33748059 PMCID: PMC7973083 DOI: 10.3389/fpubh.2021.603273] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/11/2021] [Indexed: 12/22/2022] Open
Abstract
Background: Since the coronavirus disease-2019 (COVID-19) outbreak, intensive care unit (ICU) healthcare workers were responsible for the critical infected patients. However, few studies focused on the mental health of ICU healthcare workers. This study aimed to investigate the psychological impact of COVID-19 on ICU healthcare workers in China. Methods: We distributed the nine-item Patient Health Questionnaire (PHQ-9) and seven-item General Anxiety Disorder questionnaire (GAD-7) online to ICU healthcare workers in China. Respondents were divided into frontline and second-line according to whether they have contact with COVID-19 patients. Depressive and anxiety symptoms of all respondents were evaluated based on their questionnaire scores. Results: There were 731 ICU healthcare workers finally enrolled in our study, including 303 (41.5%) male, 383 (52.4%) doctors, and 617 (84.4%) aged 26–45 years. All in all, 482 (65.9%) ICU healthcare workers reported symptoms of depression, while 429 (58.7%) reported anxiety. There was no significant difference between frontline (n = 325) and second-line (n = 406) respondents in depression (P = 0.15) and anxiety severity (P = 0.56). Logistic regression analysis showed that being female, ICU work time >5 years, and night duty number ≥10 were risk factors of developing depressive and anxiety symptoms. Income reduction was separately identified as risk of anxiety. Additionally, ICU work time >5 years was also identified as risk of developing moderate–severe depressive and anxiety symptoms. Conclusions: Frontline ICU work was not associated with higher risk of depressive and anxiety symptoms during COVID-19 pandemic remission period in China. Actions like controlling night duty number, ensuring vacation, and increasing income should be taken to relieve mental health problem. Furthermore, we should pay close attention to those who had worked long years in ICU.
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Affiliation(s)
- Xiaofan Peng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Xiangyu Meng
- Department of Urology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Li Li
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Chenghuan Hu
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Wei Liu
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Zhiyong Liu
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Xinhua Ma
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Daomiao Xu
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Zhenhua Xing
- Department of Emergency Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhaowei Zhu
- Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Bangshan Liu
- Department of Psychiatry, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Milin Peng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
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Coronavirus Disease 2019 Immediately Increases Burnout Symptoms in ICU Professionals: A Longitudinal Cohort Study. Crit Care Med 2021; 49:419-427. [PMID: 33555778 DOI: 10.1097/ccm.0000000000004865] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES ICU professionals are at risk of developing burnout due to coronavirus disease 2019. This study assesses the prevalence and incidence of burnout symptoms and moral distress in ICU professionals before and during the coronavirus disease 2019 crisis. DESIGN This is a longitudinal open cohort study. SETTING Five ICUs based in a single university medical center plus another adult ICU based on a separate teaching hospital in the Netherlands. SUBJECTS All ICU professionals were sent a baseline survey in October-December 2019 (252 respondents, response rate: 53%), and a follow-up survey was sent in May-June 2020 (233 respondents, response rate: 50%). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Burnout symptoms and moral distress measured with the Maslach Burnout Inventory and the Moral Distress Scale, respectively. The prevalence of burnout symptoms was 23.0% before coronavirus disease 2019 and 36.1% at postpeak time, with higher rates in nurses (38.0%) than in physicians (28.6%). Reversely, the incidence rate of new burnout cases among physicians was higher (26.7%) than nurses (21.9%). Higher prevalence of burnout symptoms was observed in the postpeak coronavirus disease 2019 period (odds ratio, 1.83; 95% CI, 1.32-2.53), for nurses (odds ratio, 1.77; 95% CI, 1.03-3.04), for professionals working overtime (odds ratio 2.11; 95% CI, 1.48-3.02), and for professionals directly engaged with care for coronavirus disease 2019 patients (odds ratio, 1.87; 95% CI, 1.35-2.60). Physicians were more likely than nurses to develop burnout symptoms due to coronavirus disease 2019 (odds ratio, 3.56; 95% CI, 1.06-12.21). CONCLUSIONS This study shows that overburdening of ICU professionals during an extended period of time leads to symptoms of burnout. Working long hours and under conditions of scarcity of staff, time, and resources comes at the price of ICU professionals' mental health.
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Deffner T, Rosendahl J, Niecke A. [Psychotraumatological aspects in intensive care medicine]. DER NERVENARZT 2021; 92:81-89. [PMID: 33410960 DOI: 10.1007/s00115-020-01060-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In the context of intensive care medicine, patients, their relatives, and more infrequently members of the ICU team can be affected by potential trauma. Acute stress disorder often results. Psychological symptoms of critically ill patients should therefore be regularly screened in a standardized manner in order to be able to identify and treat patients with a high symptom burden. Some traumatic stressors in intensive care medicine can be reduced using trauma-sensitive communication. Psychological and psychotherapeutic interventions can complement this basic care. High quality communication with relatives contributes to a risk reduction with regard to their subsequent psychological stress. On the part of the ICU team, stress should be differentiated from potentially traumatizing events and both problem areas should be dealt with preventively. After experiencing a traumatic event during work, a procedure analogous to physical work accidents is recommended.
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Affiliation(s)
- Teresa Deffner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Jena, Deutschland.
- Kinderklinik, Sektion Neonatologie und Pädiatrische Intensivmedizin, Universitätsklinikum Jena, Jena, Deutschland.
| | - Jenny Rosendahl
- Institut für Psychosoziale Medizin und Psychotherapie, Universitätsklinikum Jena, Jena, Deutschland
| | - Alexander Niecke
- Klinik und Poliklinik für Psychosomatik und Psychotherapie, Uniklinik & Medizinische Fakultät, Universität zu Köln, Köln, Deutschland
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Smiechowski J, Stelfox H, Sinclair S, Sinuff T, Grindrod-Millar K, Roze des Ordons A. Vicarious spiritual distress in intensive care unit healthcare providers: A qualitative study. Intensive Crit Care Nurs 2021; 63:102982. [PMID: 33454190 DOI: 10.1016/j.iccn.2020.102982] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 05/03/2020] [Accepted: 06/22/2020] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To explore the impact of caring for family members experiencing spiritual distress on Intensive Care Unit healthcare providers. DESIGN A qualitative study involving interviews and focus groups between May 2016 and April 2017. PARTICIPANTS Intensive care healthcare providers from nine teaching and three non-teaching units across Alberta, Canada. MEASUREMENTS Transcribed data were analysed using interpretive description. FINDINGS Forty-two participants variably described experiences of vicarious spiritual distress, along with coping strategies and outcomes related to these experiences. Vicarious spiritual distress was experienced as sorrow/distress, helplessness and preoccupation/rumination. Coping strategies were both adaptive (self-awareness/reflection, reframing/resiliency, team support/debriefing, self-care, accepting limitations) and maladaptive (compartmentalising/distancing, substance use). Lastly, the emotional burden of these experiences resulted in both favourable (satisfaction, appreciation) and unfavourable (moral distress, burnout, hopelessness) outcomes. CONCLUSION Our findings describe the novel concept of vicarious spiritual distress as experienced by intensive care healthcare providers and highlight the importance of identifying effective ways to support these professionals throughout their careers to prevent unfavorable outcomes and the perpetuation of maladaptive coping strategies. The adaptive coping strategies described in this study may help inform wellness initiatives and resiliency training tailored to intensive care healthcare providers.
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Affiliation(s)
- Jennifer Smiechowski
- Department of Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Center, North Tower, Room 910, 1403 29th Street NW, Calgary, Alberta T2N 2T9, Canada
| | - Henry Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, McCaig Tower, 3260 Hospital Drive NW, Calgary, Alberta T2N 426, Canada; Department of Community Health Sciences, University of Calgary, Room 3D10, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Shane Sinclair
- Faculty of Nursing, University of Calgary, Professional Faculties 2259, 2500 University Drive NW, Calgary, Alberta T2N 1N4, Canada
| | - Tasnim Sinuff
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Sunnybrook Health Sciences Center, Room D1 08, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
| | - Kathleen Grindrod-Millar
- Department of Community Health Sciences, University of Calgary, Room 3D10, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Amanda Roze des Ordons
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, McCaig Tower, 3260 Hospital Drive NW, Calgary, Alberta T2N 426, Canada; Department of Anesthesiology, Cumming School of Medicine, University of Calgary, Foothills Medical Center, North Tower, Room C222, 1403 29th Street NW, Calgary, Alberta T2N 2T9, Canada; Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Center, Education Office, 1331 29th Street NW, Calgary, Alberta T2N 4N2, Canada.
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Moynihan KM, Taylor L, Crowe L, Balnaves MC, Irving H, Ozonoff A, Truog RD, Jansen M. Ethical climate in contemporary paediatric intensive care. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106818. [PMID: 33431646 DOI: 10.1136/medethics-2020-106818] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/27/2020] [Accepted: 12/03/2020] [Indexed: 06/12/2023]
Abstract
Ethical climate (EC) has been broadly described as how well institutions respond to ethical issues. Developing a tool to study and evaluate EC that aims to achieve sustained improvements requires a contemporary framework with identified relevant drivers. An extensive literature review was performed, reviewing existing EC definitions, tools and areas where EC has been studied; ethical challenges and relevance of EC in contemporary paediatric intensive care (PIC); and relevant ethical theories. We surmised that existing EC definitions and tools designed to measure it fail to capture nuances of the PIC environment, and sought to address existing gaps by developing an EC framework for PIC founded on ethical theory. In this article, we propose a Paediatric Intensive Care Ethical Climate (PICEC) conceptual framework and four measurable domains to be captured by an assessment tool. We define PICEC as the collective felt experience of interdisciplinary team members arising from those factors that enable or constrain their ability to navigate ethical aspects of their work. PICEC both results from and is influenced by how well ethical issues are understood, identified, explored, reflected on, responded to and addressed in the workplace. PICEC encompasses four, core inter-related domains representing drivers of EC including: (1) organisational culture and leadership; (2) interdisciplinary team relationships and dynamics; (3) integrated child and family-centred care; and (4) ethics literacy. Future directions involve developing a PICEC measurement tool, with implications for benchmarking as well as guidance for, and evaluation of, targeted interventions to foster a healthy EC.
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Affiliation(s)
- Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Lisa Taylor
- Office of Ethics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Liz Crowe
- Department of Pediatric Intensive Care, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Mary-Claire Balnaves
- School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Helen Irving
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Centre for Children's Health Ethics and Law, Children's Health Queensland, Brisbane, Queensland, Australia
| | - Al Ozonoff
- Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Melanie Jansen
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Department of Pediatric Intensive Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
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Abstract
The International Research Project for the Humanization of Intensive Care Units (Proyecto HU-CI) was initiated in 2014. The aim of this project is to change the current paradigm toward a human-centered care model. Patients, families, and professionals (everyday stakeholders) were asked to describe their ideal intensive care unit (ICU). Using their opinions, 8 fields of research to improve the management of ICUs and change the reality of care throughout the world were designed. This replicable tested model to humanize the ICU care delivery model is presented.
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Affiliation(s)
- José Manuel Velasco Bueno
- Hospital Virgen de la Victoria, Málaga, Spain; International Research Project for the Humanization of Intensive Care Units (Proyecto HU-CI)
| | - Gabriel Heras La Calle
- International Research Project for the Humanization of Intensive Care Units (Proyecto HU-CI); Intensive Care Unit, Hospital Universitario de Torrejón, Madrid, Spain; Universidad Francisco de Vitoria, Madrid, Spain.
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Sarazine J, Heitschmidt M, Vondracek H, Sarris S, Marcinkowski N, Kleinpell R. Mindfulness Workshops Effects on Nurses' Burnout, Stress, and Mindfulness Skills. Holist Nurs Pract 2021; 35:10-18. [PMID: 32282563 DOI: 10.1097/hnp.0000000000000378] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Burnout decreases work performance and quality of care and can result in medical errors, lower patient satisfaction, and higher rates of turnover. A study of 68 000 registered nurses showed that 35% of hospital nurses were experiencing symptoms of burnout. A systematic review identified that mindfulness-based interventions for health care professionals reduced stress and burnout and increased self-compassion and general health. However, the authors determined that more high-quality research is needed. This study examined the impact of a 4-hour workshop on burnout syndrome, perceived stress, and mindfulness skills. The objective of this study was to determine whether a 4-hour mindfulness workshop was effective in reducing burnout and perceived levels of stress and increasing mindfulness. Nurses at a Midwest academic medical center were recruited through e-mail to attend a 4-hour mindfulness workshop. Participants completed the Maslach Burnout Inventory-Human Service Survey, Perceived Stress Scale, and Cognitive and Affective Mindfulness Scale-Revised prior to the start of the workshop and 1 and 6 months after the workshop. The study design allowed for comparisons preintervention and postintervention. Of the 52 nurses who completed the baseline questionnaires, 94% were female with an average age of 38 years. Thirty-one percent completed the questionnaires at 1 month and 20 nurses at 6 months. At 1 month, nurses reported statistically significant decreased perceptions of stress (-2.31, P = .01) and emotional exhaustion (-4.78, P = .03). Mindfulness skills, personal accomplishment, and depersonalization improved but were not statistically significant. At 6 months, statistically significant findings included increased perceptions of mindfulness (2.50, P = .04), personal accomplishment (4.43, P = .04), and decreased emotional exhaustion (-6.21, P = .05). Perceptions of stress and depersonalization improved but were not statistically significant. In this study, nurses reported decreases in burnout and perceived stress and increases in mindfulness after attending a 4-hour mindfulness workshop. Further research is needed to determine the long-term impact of mindfulness-based training on nurses' burnout, stress, and mindfulness skills. The results of this study add to the body of literature that supports the benefits of mindfulness-based interventions.
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Affiliation(s)
- Julia Sarazine
- College of Nursing, Rush University Medical Center, Chicago, Illinois. School of Nursing, Vanderbilt University, Nashville, Tennessee
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Rushton CH, Turner K. Suspending Our Agenda: Considering What Will Serve When Confronting Ethical Challenges. AACN Adv Crit Care 2020; 31:98-105. [PMID: 32168521 DOI: 10.4037/aacnacc2020569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Cynda Hylton Rushton
- Cynda Hylton Rushton is Anne and George L. Bunting Professor of Clinical Ethics, School of Nursing and Berman Institute of Bioethics at Johns Hopkins University, 525 North Wolfe St, Box 420, Baltimore, MD 21205
| | - Kathleen Turner
- Kathleen Turner is Clinical Nurse III, Medical-Surgical Intensive Care Unit, University of California San Francisco Medical Center, San Francisco, California
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Geuzinge R, Visse M, Duyndam J, Vermetten E. Social Embeddedness of Firefighters, Paramedics, Specialized Nurses, Police Officers, and Military Personnel: Systematic Review in Relation to the Risk of Traumatization. Front Psychiatry 2020; 11:496663. [PMID: 33408646 PMCID: PMC7779596 DOI: 10.3389/fpsyt.2020.496663] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 11/20/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Firefighters, paramedics, specialized nurses working in Intensive Care Units (ICUs), Operating Rooms (OR), and Emergency Rooms (ER), police officers and military personnel are more frequently exposed to potentially traumatic events than the general population; they are considered high-risk professionals. To reduce the risk of traumatization it is of great importance to be embedded in a social environment with supportive relationships. Methods: We performed a systematic review (based on the PRISMA-Guidelines) looking for social connections within the environment in which high-risk professionals are embedded (work, home, community), to obtain evidence on the impact of these connections on the risk of traumatization. Additionally, we aim to identify relevant supportive relationships in the professionals' environments. We identified the relevant scientific literature by searching, without time, and language restriction, five electronic bibliographic databases: MEDLINE, PsycINFO, Sociological Abstracts, CINAHL, and Web of Science. These databases were last searched in January 2019. Results: A qualitative analysis of the 89 eligible (out of 9,047 screened) studies shows that for firefighters, paramedics, and emergency nurses social connections in their work environment are predominantly supportive relationships and may protect them against traumatization. In other occupations (OR-nurses, ICU-nurses, police officers), however, social connections at work are not only a source of support but are also a source of stress. For military personnel study results are inconclusive as to whether their social connections at work or at home support them against traumatization. In so far as connections are supportive, their sources vary greatly from one occupational group to another; they differ between work vs. home as well as within work between peers vs. supervisor. Conclusions: Being embedded in a social environment, i.e., having social connections, is important but not always sufficient to protect high-risk professionals against traumatization. For, while these connections may be the antecedents of supportive relationships, they can also be the antecedents of damaging relationships. Additionally, the sources of supportive relationships differ among groups. This suggests that knowledge of how the social structures of the occupational groups differ may increase our understanding of the impact of social connections and relationships, including socialization, on the risk of traumatization of high-risk professionals.
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Affiliation(s)
- Renate Geuzinge
- Humanism and Social Resilience, University of Humanistic Studies, Utrecht, Netherlands
| | - Merel Visse
- Care Ethics, University of Humanistic Studies, Utrecht, Netherlands
| | - Joachim Duyndam
- Humanism and Social Resilience, University of Humanistic Studies, Utrecht, Netherlands
| | - Eric Vermetten
- Department of Psychiatry, Leiden University Medical Center, Leiden, Netherlands
- Ministry of Defense, Military Mental Health Research Center, Utrecht, Netherlands
- ARQ National Psychotrauma Center, Diemen, Netherlands
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Bateman ME, Hammer R, Byrne A, Ravindran N, Chiurco J, Lasky S, Denson R, Brown M, Myers L, Zu Y, Denson JL. Death Cafés for prevention of burnout in intensive care unit employees: study protocol for a randomized controlled trial (STOPTHEBURN). Trials 2020; 21:1019. [PMID: 33308290 PMCID: PMC7729694 DOI: 10.1186/s13063-020-04929-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 11/25/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Burnout is an occupational syndrome that leads to mental health problems, job turnover, and patient safety events. Those caring for critically ill patients are especially susceptible due to high patient mortality, long hours, and regular encounters with trauma and ethical issues. Interventions to prevent burnout in this population are needed. Preliminary studies suggest debriefing sessions may reduce burnout. This study aims to assess whether participation in regular debriefing can prevent burnout in intensive care unit (ICU) clinicians. METHODS A randomized controlled trial will be conducted in two large academic medical centers. Two hundred ICU clinicians will be recruited with target enrollment of 100 physicians and 100 non-physicians (nurses, pharmacists, therapists). Participants must have worked in the ICU for the equivalent of at least 1 full time work week in the preceding 4 weeks. Enrolled subjects will be randomized to virtually attend biweekly debriefing sessions facilitated by a psychotherapist for 3 months or to a control arm without sessions. Our debriefs are modeled after Death Cafés, which are informal discussions focusing on death, dying, loss, grief, and illness. These sessions allow for reflection on distressing events and offer community and collaboration among hospital employees outside of work. The primary outcome is clinician burnout as measured by the Maslach Burnout Inventory (MBI) Score. Secondary outcomes include depression and anxiety, as measured by the Patient Health Questionnaire 8 (PHQ-8) and Generalized Anxiety Disorder 7-item scale (GAD-7), respectively. Questionnaires will be administered prior to the intervention, at 1 month, at 3 months, and at 6 months after enrollment. These values will be compared between groups temporally. Qualitative feedback will also be collected and analyzed. DISCUSSION With ICU clinician burnout rates exceeding 50%, Death Café debriefing sessions may prove to be an effective tool to avert this debilitating syndrome. With COVID-19 limiting social interactions and overloading ICUs worldwide, the virtual administration of the Death Café for ICU clinicians provides an innovative strategy to potentially mitigate burnout in this vulnerable population. TRIAL REGISTRATION ClinicalTrials.gov NCT04347811 . Registered on 15 April 2020.
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Affiliation(s)
- Marjorie E Bateman
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA.
| | - Rachel Hammer
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
- Department of Psychiatry, Tulane University School of Medicine, New Orleans, LA, USA
| | - Abigail Byrne
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - Nithya Ravindran
- Department of Psychiatry, Tulane University School of Medicine, New Orleans, LA, USA
| | - Jennifer Chiurco
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - Sasha Lasky
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - Rebecca Denson
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - Margo Brown
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - Leann Myers
- Department of Biostatistics and Data Science, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Yuanhao Zu
- Department of Biostatistics and Data Science, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Joshua L Denson
- Department of Medicine, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
- Section of Pulmonary Diseases, Critical Care & Environmental Medicine, Tulane University School of Medicine, New Orleans, LA, USA
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Liu X, Chen J, Wang D, Li X, Wang E, Jin Y, Ma Y, Yu C, Luo C, Zhang L, Liu C, Zhou Y, Yang L, Song J, Bai T, Hou X. COVID-19 Outbreak Can Change the Job Burnout in Health Care Professionals. Front Psychiatry 2020; 11:563781. [PMID: 33363480 PMCID: PMC7753007 DOI: 10.3389/fpsyt.2020.563781] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 11/06/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The outbreak of COVID-19 in China was a sudden bio-disaster, which may bring a negative impact on the job burnout of health care professionals (HCPs). Objective: We aim to find out the association factors, especially those closely related to this outbreak, of job burnout in Chinese HCPs. Method: The cross-sectional survey about HCPs' job burnout based on a network platform was conducted in high and low infection regions during the COVID-19 outbreak in China. The demographic characteristics, medical-work-related factors, risk of getting infected due to occupational exposure, and family factors were collected by the self-reported questionnaire. The Chinese version of the Maslach Burnout Inventory (CMBI) and the Trait Coping Style Questionnaire (TCSQ) were employed in this study to evaluate the job burnout and coping style, respectively. Furthermore, statistical analysis was done to find out the associated factors of job burnout. Results: We collected 880 complete questionnaires from doctors and nurses from February 9, 2020 to February 11, 2020. In this study, the positive rates of three dimensions of burnout (emotional exhaustion, depersonalization, and reduced personal accomplishment) and overall burnout were 9.09, 50.57, 56.59, and 73.98%, respectively. After the statistical analysis, we found that several factors can independently affect the dimensions. Working in the high infection region and negative coping styles can affect all three dimensions at once. More night shift quantity and having symptoms could increase emotional exhaustion and depersonalization, while higher work intensity and senior title could increase emotional exhaustion and reduce personal accomplishment, respectively. Conclusion: The rate of moderate and severe burnout had increased due to the outbreak. More attention should be paid to burnout in HCPs, especially those with negative coping. There were some potential ways to reduce burnout, such as reducing their workload and providing better protection from the virus.
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Affiliation(s)
- Xinghuang Liu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jie Chen
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dongke Wang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Li
- Department of Paediatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Erchuan Wang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Jin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanling Ma
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cheng Yu
- Ultrasonic Department, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chang Luo
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Zhang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chuang Liu
- Wuhan Estrip Tech Co., Ltd., Wuhan, China
| | | | - Ling Yang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Song
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tao Bai
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaohua Hou
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Szawarski P. Medicine and the human factor. Postgrad Med J 2020; 96:784-787. [PMID: 33115910 DOI: 10.1136/postgradmedj-2020-138943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/07/2020] [Accepted: 09/12/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Piotr Szawarski
- Anaesthesia and Intensive Care Medicine, Wexham Park Hospital, Slough, UK
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Abstract
Supplemental Digital Content is available in the text. ICU is a multifaceted organization where multiple teams care for critically ill patients. In the current era, collaboration between teams and efficient workflows form the backbone of value-based care. Geographical cohorting is a widespread model for hospitalist rounding, but its role in ICUs is unclear. This study evaluates the outcomes of geographical cohorting in a large ICU of an Academic Health Center.
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Exploring the Relational Intervention of Storytelling: A Qualitative Study of the Patient Stories Project in a Single ICU. Crit Care Explor 2020; 2:e0224. [PMID: 33063029 PMCID: PMC7523772 DOI: 10.1097/cce.0000000000000224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objectives: Our study objective was to explore nurses’ experiences of how the Patient Stories Project, an intervention consisting of garnering and sharing ICU survivor stories with the ICU team, influenced their perceptions of the value of their work and their nurse-patient relationships. Design: This was a qualitative descriptive case study that used thematic analysis. Setting: This study was conducted in a single, 34-bed adult ICU in a Canadian tertiary care teaching hospital, serving a mixed medical and surgical patient population and employing over 200 nurses. Subjects: Semistructured focus groups with 12 ICU nurses were conducted between June 2019 and July 2019. Intervention: The Patient Stories Project is a systematic process for collecting and sharing former patients’ stories. On a regular basis, former ICU patients return to the ICU to say, “thank you,” share their experiences, and tell their stories to staff. Measurements and Main Results: Storytelling through the Patient Stories Project gives meaning to nurses’ work and provides avenues for nurses to think about their work more positively. Key themes were as follows: 1) perspective taking, 2) emphasizing the value in caring, 3) providing positive closure, 4) engendering team belonging, and 5) building a sense of hope. Conclusions: This study addresses the Critical Care Societies Collaboratives “call to action” to create a healthy work environment. Nurse focus group participants articulated how an initiative such as the Patient Stories Project may augment the relational aspects of work that are important to nurses, as well as their patients and families. Our study results have implications for the importance of using storytelling as a relational strategy to protect against depersonalization and cynicism, elements of burnout.
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Sharp M, Burkart KM, Adelman MH, Ashton RW, Daugherty Biddison L, Bosslet GT, Doyle ST, Eckmann T, Khurram S Khan MM, Lenz PH, McCallister JW, O'Toole J, Rand CS, Riekert KA, Soffler MI, Winter GR, Zaeh S, Eakin MN. A National Survey of Burnout and Depression Among Fellows Training in Pulmonary and Critical Care Medicine: A Special Report by the Association of Pulmonary and Critical Care Medicine Program Directors. Chest 2020; 159:733-742. [PMID: 32956717 PMCID: PMC7856531 DOI: 10.1016/j.chest.2020.08.2117] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The prevalence of burnout and depressive symptoms is high among physician trainees. RESEARCH QUESTION What is the burden of burnout and depressive symptoms among fellows training in pulmonary and critical care medicine (PCCM) and what are associated individual fellow, program, and institutional characteristics? STUDY DESIGN AND METHODS We conducted a cross-sectional electronic survey of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States to assess burnout and depressive symptoms. Burnout symptoms were measured using the Maslach Burnout Index two-item measure. The two-item Primary Care Evaluation of Mental Disorders Procedure was used to screen for depressive symptoms. For each of the two outcomes (burnout and depressive symptoms), we constructed three multivariate logistic regression models to assess individual fellow characteristics, program structure, and institutional polices associated with either burnout or depressive symptoms. RESULTS Five hundred two of the 976 fellows who received the survey completed it-including both outcome measures-giving a response rate of 51%. Fifty percent of fellows showed positive results for either burnout or depressive symptoms, with 41% showing positive results for depressive symptoms, 32% showing positive results for burnout, and 23% showing positive results for both. Reporting a coverage system in the case of personal illness or emergency (adjusted OR [aOR], 0.44; 95% CI, 0.26-0.73) and access to mental health services (aOR, 0.14; 95% CI, 0.04-0.47) were associated with lower odds of burnout. Financial concern was associated with higher odds of depressive symptoms (aOR, 1.13; 95% CI, 1.05-1.22). Working more than 70 hours in an average clinical week and the burdens of electronic health record (EHR) documentation were associated with a higher odds of both burnout and depressive symptoms. INTERPRETATION Given the high prevalence of burnout and depressive symptoms among fellows training in PCCM, an urgent need exists to identify solutions that address this public health crisis. Strategies such as providing an easily accessible coverage system, access to mental health resources, reducing EHR burden, addressing work hours, and addressing financial concerns among trainees may help to reduce burnout or depressive symptoms and should be studied further by the graduate medical education community.
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Affiliation(s)
- Michelle Sharp
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Kristin M Burkart
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Mark H Adelman
- Division of Pulmonary, Critical Care and Sleep Medicine, NYU Grossman School of Medicine, New York, NY
| | - Rendell W Ashton
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland
| | - Lee Daugherty Biddison
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gabriel T Bosslet
- Division of Pulmonary, Critical Care, Allergy, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Stephen T Doyle
- Division of Pulmonary, Critical Care and Sleep Medicine, Spectrum Health, Grand Rapids, MI
| | - Thomas Eckmann
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Malik M Khurram S Khan
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kentucky, Lexington, KY
| | - Peter H Lenz
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati Medical Center, Cincinnati
| | - Jennifer W McCallister
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jacqueline O'Toole
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cynthia S Rand
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kristin A Riekert
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Morgan I Soffler
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Gretchen R Winter
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Sandra Zaeh
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michelle N Eakin
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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The Role of Psychiatry in Treating Burnout Among Nurses During the Covid-19 Pandemic. JOURNAL OF RADIOLOGY NURSING 2020; 39:176-178. [PMID: 32837392 PMCID: PMC7377731 DOI: 10.1016/j.jradnu.2020.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The prevalence of burnout among US registered nurses ranges from 35 to 45%. In one study, nurses had twice the rate of depression compared with other health care professionals. Owing to the Covid-19 pandemic, burnout is a major threat to the stability of the workforce on the front lines. Consultation-liaison (C/L) psychiatry can provide assistance through liaison meetings, stress management programs, and curbside consults to help reduce the risk of burnout. Narrative medicine programs, mindfulness-based stress reduction, and meditation apps are additional means to alleviate stress. Given the current challenges facing C/L psychiatry and the mental health field in general, there is an urgent need to overcome stigma and financial barriers to make treatment readily accessible.
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Bilhimer M, Acquisto NM, Slocum GW, Cocchio C, Groth M, Rozycki E, Sturgill M, Weant K, Bridgeman P. A cross‐sectional survey of U.S. hospital pharmacy leaders on departmental initiatives to address burnout. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Matt Bilhimer
- Department of Pharmacy Olathe Medical Center Olathe Kansas USA
| | - Nicole M. Acquisto
- Departments of Pharmacy and Emergency Medicine University of Rochester Medical Center Rochester New York USA
| | - Giles W. Slocum
- Department of Pharmacy Rush University Medical Center Chicago Illinois USA
| | - Craig Cocchio
- CHRISTUS Trinity Mother Frances Hospital Tyler Texas USA
| | - Meghan Groth
- GlaxoSmithKline Pharmaceuticals Worcester Massachusetts USA
| | - Elizabeth Rozycki
- Department of Pharmacy The Ohio State University Wexner Medical Center Columbus Ohio USA
| | - Marc Sturgill
- Department of Pharmacy Services Robert Wood Johnson University Hospital/Rutgers University New Brunswick New Jersey USA
| | - Kyle Weant
- Department of Pharmacy Medical University of South Carolina Charleston South Carolina USA
| | - Patrick Bridgeman
- Department of Pharmacy Services Robert Wood Johnson University Hospital/Rutgers University New Brunswick New Jersey USA
- Ernest Mario School of Pharmacy, Rutgers The State University of New Jersey Piscataway New Jersey USA
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Smiechowski J, Stelfox H, Sinclair S, Sinuff T, Grindrod-Millar K, Roze des Ordons A. WITHDRAWN: Vicarious spiritual distress in intensive care unit healthcare providers: A qualitative study. Intensive Crit Care Nurs 2020:102913. [PMID: 32819807 DOI: 10.1016/j.iccn.2020.102913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 05/03/2020] [Accepted: 06/22/2020] [Indexed: 11/26/2022]
Abstract
This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
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Affiliation(s)
- Jennifer Smiechowski
- Department of Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Center, North Tower, Room 910, 1403 29th Street NW, Calgary, Alberta T2N 2T9, Canada
| | - Henry Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, McCaig Tower, 3260 Hospital Drive NW, Calgary, Alberta T2N 426, Canada; Department of Community Health Sciences, University of Calgary, Room 3D10, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Shane Sinclair
- Faculty of Nursing, University of Calgary, Professional Faculties 2259, 2500 University Drive NW, Calgary, Alberta T2N 1N4, Canada
| | - Tasnim Sinuff
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Sunnybrook Health Sciences Center, Room D1 08, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
| | - Kathleen Grindrod-Millar
- Department of Community Health Sciences, University of Calgary, Room 3D10, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Amanda Roze des Ordons
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, McCaig Tower, 3260 Hospital Drive NW, Calgary, Alberta T2N 426, Canada; Department of Anesthesiology, Cumming School of Medicine, University of Calgary, Foothills Medical Center, North Tower, Room C222, 1403 29th Street NW, Calgary, Alberta T2N 2T9, Canada; Division of Palliative Medicine, Department of Oncology, Cumming School of Medicine, University of Calgary, Tom Baker Cancer Center, Education Office, 1331 29th Street NW, Calgary, Alberta T2N 4N2, Canada.
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[Psychotraumatological aspects in intensive care medicine]. Med Klin Intensivmed Notfmed 2020; 115:511-518. [PMID: 32749505 DOI: 10.1007/s00063-020-00706-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/16/2020] [Accepted: 04/21/2020] [Indexed: 10/23/2022]
Abstract
In the context of intensive care medicine, patients, their relatives, and more infrequently members of the ICU team can be affected by potential trauma. Acute stress disorder often results. Psychological symptoms of critically ill patients should therefore be regularly screened in a standardized manner in order to be able to identify and treat patients with a high symptom burden. Some traumatic stressors in intensive care medicine can be reduced using trauma-sensitive communication. Psychological and psychotherapeutic interventions can complement this basic care. High quality communication with relatives contributes to a risk reduction with regard to their subsequent psychological stress. On the part of the ICU team, stress should be differentiated from potentially traumatizing events and both problem areas should be dealt with preventively. After experiencing a traumatic event during work, a procedure analogous to physical work accidents is recommended.
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Vargas M, Spinelli G, Buonanno P, Iacovazzo C, Servillo G, De Simone S. Burnout Among Anesthesiologists and Intensive Care Physicians: Results From an Italian National Survey. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2020; 57:46958020919263. [PMID: 32713227 PMCID: PMC7383656 DOI: 10.1177/0046958020919263] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Burnout is one of the main chronic health problems with negative consequences on caregivers but also on the quality of care. This is a multidimensional occupational syndrome, characterized by three main criteria: emotional exhaustion (EE), depersonalization (DP), and low personal accomplishment (PA). Burnout is particularly identified in professionals working in caregiving and human services, especially the ones who are interpersonally stressed and emotionally vulnerable. Intensive care professionals seem to face a critical risk of burnout. This study aiming to evaluate the occurrence and the risk factors of burnout among Italian anesthesiologists and intensive care physicians. All members included in the mailing list of the Italian Society of Anesthesia, Analgesia, and Intensive Care were invited to participate in an online survey. An anonymous questionnaire was distributed via a specific website. Burnout was measured using the Maslach Burnout Inventory (MBI) questionnaire. All responses were evaluated through univariate and multivariable logistic regression. A total of 859 physicians out of 3,654 (23.5%) participated in this online survey. According to the MBI criteria for a high degree of burnout, 10.2% (88) of the respondents reported high EE, high DP, and low PA together; 79.9% (686) exhibited a moderate degree of burnout; and 9.9% (85) reported a low degree of burnout, with normal values in all three of the explored psychological dimensions. This study reported mostly a moderate level of burnout among Italian anesthesiologist and intensive care physicians since we found 10.2% incidence for high degree of burnout according to the MBI criteria.
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Affiliation(s)
- Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Gianmario Spinelli
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Pasquale Buonanno
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Carmine Iacovazzo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - Stefania De Simone
- Institute for Research on Innovation and Services for Development, National Research Council of Italy, Naples, Italy
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Abstract
BACKGROUND Ethical conflict and subsequent nurse moral distress and burnout are common in the intensive care unit. There is a gap in our understanding of nurses' perceptions of how organizational resources support them in addressing ethical conflict in the intensive care unit. RESEARCH QUESTION/OBJECTIVES/METHODS The aim of this qualitative, descriptive study was to explore how nurses experience ethical conflict and use organizational resources to support them as they address ethical conflict in their practice. PARTICIPANTS AND RESEARCH CONTEXT Responses to two open-ended questions were collected from critical care nurses working in five intensive care units at a large, academic medical center in the Midwestern region of the United States. ETHICAL CONSIDERATIONS This study was approved by the Institutional Review Board at the organization where the study took place. FINDINGS Three main interwoven themes emerged: nurses perceive (1) intensive care unit culture, practices, and organizational priorities contribute to patient suffering; (2) nurses are marginalized during ethical conflict in the intensive care unit; and (3) organizational resources have the potential to reduce nurse moral distress. Nurses identified ethics education, interprofessional dialogue, and greater involvement of nurses as important strategies to improve the management of ethical conflict. DISCUSSION Ethical conflict related to healthcare system challenges is intrinsic in the daily practice of critical care nurses. Nurses want to be engaged in discussions about their perspectives on ethical conflict and play an active role in addressing ethical conflict in their practice. Organizational resources that support nurses are vital to the resolution of ethical conflict. CONCLUSION These findings can inform the development of interventions that aim to proactively and comprehensively address ethical conflict in the intensive care unit to reduce nurse moral distress and improve the delivery of patient and family care.
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Affiliation(s)
- Natalie S McAndrew
- University of Wisconsin-Milwaukee, USA; Froedtert & the Medical College of Wisconsin, USA
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Robert R, Kentish-Barnes N, Boyer A, Laurent A, Azoulay E, Reignier J. Ethical dilemmas due to the Covid-19 pandemic. Ann Intensive Care 2020; 10:84. [PMID: 32556826 PMCID: PMC7298921 DOI: 10.1186/s13613-020-00702-7] [Citation(s) in RCA: 150] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/11/2020] [Indexed: 01/04/2023] Open
Abstract
The devastating pandemic that has stricken the worldwide population induced an unprecedented influx of patients in ICUs, raising ethical concerns not only surrounding triage and withdrawal of life support decisions, but also regarding family visits and quality of end-of-life support. These ingredients are liable to shake up our ethical principles, sharpen our ethical dilemmas, and lead to situations of major caregiver sufferings. Proposals have been made to rationalize triage policies in conjunction with ethical justifications. However, whatever the angle of approach, imbalance between utilitarian and individual ethics leads to unsolvable discomforts that caregivers will need to overcome. With this in mind, we aimed to point out some critical ethical choices with which ICU caregivers have been confronted during the Covid-19 pandemic and to underline their limits. The formalized strategies integrating the relevant tools of ethical reflection were disseminated without deviating from usual practices, leaving to intensivists the ultimate choice of decision.
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Affiliation(s)
- René Robert
- Université de Poitiers, Poitiers, France.
- Inserm CIC 1402, Axe Alive, Poitiers, France.
- Service de Médecine Intensive Réanimation, CHU Poitiers, Poitiers, France.
| | - Nancy Kentish-Barnes
- Service de Réanimation Médicale, APHP, CHU Saint-Louis, Paris, France
- Groupe de Recherche Famiréa, Paris, France
| | - Alexandre Boyer
- Université de Bordeaux, Bordeaux, France
- Service de Médecine Intensive Réanimation, CHU Bordeaux, Bordeaux, France
| | - Alexandra Laurent
- Laboratoire psy-DREPI, Université de Bourgogne Franche-Comté, 7458, Dijon, France
- Service de Réanimation Chirurgicale, Dijon, France
| | - Elie Azoulay
- Service de Réanimation Médicale, APHP, CHU Saint-Louis, Paris, France
- Groupe de Recherche Famiréa, Paris, France
| | - Jean Reignier
- Université de Nantes, Nantes, France
- Service de Médecine Intensive Réanimation, CHU de Nantes, Nantes, France
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Sessler CN. Intensivist Burnout: Running on Empty? Chest 2020; 156:817-819. [PMID: 31699227 DOI: 10.1016/j.chest.2019.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/22/2019] [Accepted: 08/03/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
- Curtis N Sessler
- Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Richmond, VA.
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Abstract
PURPOSE OF REVIEW The purposes of this discussion are to describe what is known about burnout among women physicians and identify contributing factors, categories of impact, and methods for mitigating the phenomenon. The authors conclude with current gaps in research. RECENT FINDINGS Although there are a lack of investigations analyzing and reporting physician burnout data by gender, there is evidence to suggest that women physicians experience stress and burnout differently than their men counterparts. Women physicians are more likely to face gender discrimination, gender biases, deferred personal life decisions, and barriers to professional advancement, all of which may contribute to burnout. Interventions specific to preventing physician burnout in women should include (1) addressing barriers to career satisfaction, work life integration, and mental health; (2) identification and reduction of gender and maternal bias; (3) mentorship and sponsorship opportunities; (4) family leave, lactation, and child care policies and support. In addition, gaps in research must be addressed in an effort to inform best practices for measuring and addressing burnout among women physicians.
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Interprofessional Shared Decision-Making in the ICU: A Systematic Review and Recommendations From an Expert Panel. Crit Care Med 2020; 47:1258-1266. [PMID: 31169620 DOI: 10.1097/ccm.0000000000003870] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES There is growing recognition that high-quality care for patients and families in the ICU requires exemplary interprofessional collaboration and communication. One important aspect is how the ICU team makes complex decisions. However, no recommendations have been published on interprofessional shared decision-making. The aim of this project is to use systematic review and normative analysis by experts to examine existing evidence regarding interprofessional shared decision-making, describe its principles and provide ICU clinicians with recommendations regarding its implementation. DATA SOURCES We conducted a systematic review using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases and used normative analyses to formulate recommendations regarding interprofessional shared decision-making. STUDY SELECTION Three authors screened titles and abstracts in duplicate. DATA SYNTHESIS Four papers assessing the effect of interprofessional shared decision-making on quality of care were identified, suggesting that interprofessional shared decision-making is associated with improved processes and outcomes. Five recommendations, largely based on expert opinion, were developed: 1) interprofessional shared decision-making is a collaborative process among clinicians that allows for shared decisions regarding important treatment questions; 2) clinicians should consider engaging in interprofessional shared decision-making to promote the most appropriate and balanced decisions; 3) clinicians and hospitals should implement strategies to foster an ICU climate oriented toward interprofessional shared decision-making; 4) clinicians implementing interprofessional shared decision-making should consider incorporating a structured approach; and 5) further studies are needed to evaluate and improve the quality of interprofessional shared decision-making in ICUs. CONCLUSIONS Clinicians should consider an interprofessional shared decision-making model that allows for the exchange of information, deliberation, and joint attainment of important treatment decisions.
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Gibiino G, Rugo M, Maffoni M, Giardini A. Back to the future: five forgotten lessons for the healthcare managers of today. Int J Qual Health Care 2020; 32:275-277. [DOI: 10.1093/intqhc/mzaa021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 01/30/2020] [Accepted: 02/26/2020] [Indexed: 12/13/2022] Open
Abstract
AbstractNowadays, political, economic and technological upheavals require the rediscovery of some elapsed soft skills by healthcare managers. These abilities are values grounded in the past and somewhat nebulous in the present. We suggest five forgotten lessons highlighting the importance of a stronger human and self-conscious approach in today’s and tomorrow’s healthcare managers.
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Affiliation(s)
- Giovanni Gibiino
- Casa di Cura Gibiino, Viale Odorico da Pordenone, 25, 95128 Catania, Italy
| | - Michele Rugo
- Residenza Gruber Bologna, IRPA, Via Alessandro Pestalozza, 12/14, 20149 Milano Italy
| | - Marina Maffoni
- Department of Brain and Behavioral Sciences, University of Pavia, Corso Str. Nuova, 65, 27100 Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano (PV), Italy
| | - Anna Giardini
- Istituti Clinici Scientifici Maugeri IRCCS, Psychology Unit of Montescano Institute, Montescano (PV), Italy
- Istituti Clinici Scientifici Maugeri IRCCS Pavia, Istituto Scientifico di Montescano (PV), Via Maugeri 4, 27100 Pavia, Italy
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Zhang H, Ye Z, Tang L, Zou P, Du C, Shao J, Wang X, Chen D, Qiao G, Mu SY. Anxiety symptoms and burnout among Chinese medical staff of intensive care unit: the moderating effect of social support. BMC Psychiatry 2020; 20:197. [PMID: 32357865 PMCID: PMC7195710 DOI: 10.1186/s12888-020-02603-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 04/15/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Social support can be a critical resource to help medical staff cope with stressful events; however, the moderating effect of social support on the relationship between burnout and anxiety symptoms has not yet been explored. METHODS The final sample was comprised of 514 intensive care unit physicians and nurses in this cross-sectional study. Questionnaires were used to collect data. A moderated model was used to test the effect of social support. RESULTS The moderating effect of social support was found to be significant (b = - 0.06, p = 0.04, 95%CI [- 0.12, - 0.01]). The Johnson-Neyman technique indicated that when social support scores were above 4.26 among intensive care unit medical staff, burnout was not related to anxiety symptoms. CONCLUSIONS This is the first study to test the moderating effect of social support on the relationship between burnout and anxiety symptoms among intensive care unit staff.
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Affiliation(s)
- Hui Zhang
- grid.13402.340000 0004 1759 700XZhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, 310016 Zhejiang China
| | - ZhiHong Ye
- Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, 310016, Zhejiang, China.
| | - Leiwen Tang
- grid.13402.340000 0004 1759 700XZhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, 310016 Zhejiang China
| | - Ping Zou
- grid.260989.c0000 0000 8588 8547School of Nursing, Nipissing University, 750 Dundas Street West, Toronto, Ontario Canada
| | - Chunxue Du
- grid.459540.90000 0004 1791 4503Guizhou Provincial People’s Hospital, Guiyang, 550002 Guizhou China
| | - Jing Shao
- grid.13402.340000 0004 1759 700XZhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, 310016 Zhejiang China
| | - Xiyi Wang
- grid.13402.340000 0004 1759 700XZhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, 310016 Zhejiang China
| | - Dandan Chen
- grid.13402.340000 0004 1759 700XZhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, 310016 Zhejiang China
| | - Guojing Qiao
- grid.452244.1The Affiliated Hospital of Guizhou Medical University, Guiyang, 550001 Guizhou China
| | - Shao Yu Mu
- grid.203458.80000 0000 8653 0555Nursing College of Chongqing Medical University, Chongqing, 400016 China
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Dwyer Kaluzna S, Benken ST, Petzel Gimbar R, DiDomenico RJ. Combating pharmacist burnout: A model for critical care clinical pharmacy faculty. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | - Scott T. Benken
- Department of Pharmacy Practice University of Illinois at Chicago Chicago Illinois
| | - Renee Petzel Gimbar
- Department of Pharmacy Practice University of Illinois at Chicago Chicago Illinois
| | - Robert J. DiDomenico
- Department of Pharmacy Practice University of Illinois at Chicago Chicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research University of Illinois at Chicago Chicago Illinois
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85
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Burnout, Compassion Fatigue, and Secondary Trauma in Nurses: Recognizing the Occupational Phenomenon and Personal Consequences of Caregiving. Crit Care Nurs Q 2020; 43:73-80. [PMID: 31789880 DOI: 10.1097/cnq.0000000000000293] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Burnout and compassion fatigue describe the state of health care professionals' extended stress, emotional states, and prolonged duress after events. In the past few decades, burnout and compassion fatigue have received increased focus and attention. This article summarizes the evolution in moving from viewing burnout as an individual's problem to understanding burnout as an occupational phenomenon, additionally recognizing the powerful role secondary trauma contributes to compassion fatigue. As such, the causes and addressing the solutions of burnout are multifaceted and complex. Causes of burnout stem from external pressure of caring for patients and pressure from organizational policy and practices, including unhealthy work environments, poor communication, stigma, and more. The harm from burnout and secondary trauma in health care professionals can be profound, impacting a significant portion of the workforce and manifesting in real suffering, including depression, emotional trauma, and suicide. As health care professionals are daily at risk, the need to recognize, address, and treat burnout is a priority. Both personal resilience building activities for effective stress reduction in clinicians and system-level solutions to address root causes must be utilized to address burnout.
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Abstract
BACKGROUND Moral distress was first described by Jameton in 1984, and has been defined as distress experienced by an individual when they are unable to carry out what they believe to be the right course of action because of real or perceived constraints on that action. This complex phenomenon has been studied extensively among healthcare providers, and intensive care professionals in particular report high levels of moral distress. This distress has been associated with provider burnout and associated consequences such as job attrition, with potential impacts on patient and family care. There is a paucity of literature exploring how middle and late career healthcare providers experience and cope with moral distress. OBJECTIVES We explore the experience of moral distress and the strategies and resources invoked to mitigate that distress in mid- and late-career healthcare providers practicing in paediatric intensive care, in order to identify ways in which the work environment can build a culture of moral resilience. RESEARCH DESIGN An exploratory, qualitative quality improvement project utilizing focus group and semi-structured interviews with pediatric intensive care front-line providers. PARTICIPANTS Mid-and-later career (10 + years in practice) pediatric intensive care front line providers in a tertiary pediatric hospital. RESEARCH CONTEXT This work focuses on paediatric intensive care providers in a single critical care unit, in order to explore the site-specific perspectives of health care providers in that context with respect to moral distress coping strategies. ETHICAL CONSIDERATIONS The study was approved by the Quality Management Office at the institution; consent was obtained from participants, and no identifying data was included in this project. FINDINGS Participants endorsed perspective-building and described strategies for positive adaptation including; active, reflective and structured supports. Participants articulated interest in enhanced and accessible formal supports. DISCUSSION Findings in this study resonate with the current literature in healthcare provider moral distress, and exposed ways in which the work environment could support a culture of moral resilience. Avenues are described for the management and mitigation of moral distress in this setting. CONCLUSION This exploratory work lays the groundwork for interventions that facilitate personal growth and meaning in the midst of moral crises in critical care practice.
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Gajra A, Bapat B, Jeune-Smith Y, Nabhan C, Klink AJ, Liassou D, Mehta S, Feinberg B. Frequency and Causes of Burnout in US Community Oncologists in the Era of Electronic Health Records. JCO Oncol Pract 2020; 16:e357-e365. [DOI: 10.1200/jop.19.00542] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND: Physician burnout, characterized by exhaustion of physical or emotional strength, cynicism, and lack of achievement, has become a worsening phenomenon in medicine, contributing to higher health care costs and patient/physician dissatisfaction. How burnout has affected hematologists and oncologists is not well studied. METHODS: US community oncologists/hematologists were queried via a Web-based survey from September-November 2018. Physicians were asked about frequency of burnout symptoms, drivers of work-related stress, and their perceptions on management of workload. RESULTS: Among the 163 physicians surveyed, 46% felt a substantial amount of stress at work. Most physicians felt emotionally (85%) and physically (87%) exhausted. A majority of physicians felt lethargic (67%), ineffective (64%), and/or detached (63%). In a typical workweek, 93% needed time beyond time allocated to clinical care to complete work responsibilities. Electronic health record (EHR) responsibilities caused moderate to excessive stress at work for 67% of physicians; 79% of physicians worked on EHRs outside of clinic hours. Other sources of excessive stress were changing reimbursement models (33%), interactions with payers (31%), and increasing patient and caregiver demands (31%). A third of physicians have considered retiring early or changing their career path to cope. To combat burnout, physicians’ practices have used advanced practice providers, invested in information technology, and/or hired additional administrative staff. However, the majority of physicians stated they had optimal or good control over their workload. CONCLUSION: Most oncologists experience burnout symptoms and require additional time beyond that allocated to clinical care to complete their workload. The discordance between oncologists’ admission of stress and exhaustion while claiming good control over those same burdens warrants exploration in future research.
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Affiliation(s)
- Ajeet Gajra
- Cardinal Health Specialty Solutions, Dublin, OH
| | - Bela Bapat
- Cardinal Health Specialty Solutions, Dublin, OH
| | | | | | | | | | - Sonam Mehta
- Cardinal Health Specialty Solutions, Dublin, OH
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Hope AA, Munro CL. Leading Systems Toward Improving Professional Well-being. Am J Crit Care 2020; 29:84-86. [PMID: 32114619 DOI: 10.4037/ajcc2020652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Aluko A. Hope
- Aluko A. Hope is coeditor in chief of the American Journal of Critical Care. He is an associate professor at Albert Einstein College of Medicine and an intensivist and assistant bioethics consultant at Montefiore Medical Center, both in New York City
| | - Cindy L. Munro
- Cindy L. Munro is coeditor in chief of the American Journal of Critical Care. She is dean and professor, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida
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90
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Hoover EB, Butaney B, Stoehr JD. Exploring the Effectiveness of Mindfulness and Decentering Training in a Physician Assistant Curriculum. J Physician Assist Educ 2020; 31:19-22. [PMID: 31977963 DOI: 10.1097/jpa.0000000000000288] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
PURPOSE Several studies have documented the effects of physician assistant (PA) training on students' perceived stress and life satisfaction. Innovative curriculum design incorporating effective stress management resources may help address this concern. METHODS Mindfulness and decentering training was incorporated into a first-quarter course for PA students. It included lecture, in-class demonstrations and practice, and out-of-class activities. Mindfulness (Experiences Questionnaire; Acceptance and Action Questionnaire) and general well-being (Satisfaction with Life Scale; Perceived Stress Scale) were assessed precourse, postcourse, and during follow-up. RESULTS Students reported a significant increase in levels of mindfulness postcourse, which remained stable at a 4-month follow-up. These findings were consistent regardless of prior mindfulness practice. More importantly, changes in the levels of mindfulness significantly predicted changes in life satisfaction and perceived stress. CONCLUSION Stress management resources can be incorporated into PA courses through innovative curriculum design to help students cope with the demands of PA school.
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Affiliation(s)
- Eve B Hoover
- Eve B. Hoover, DMSc, PA-C, is an assistant professor in the physician assistant program at Midwestern University, Glendale, Arizona
- Bhupin Butaney, PhD, is an associate professor in the clinical psychology program at Midwestern University, Glendale, Arizona
- James D. Stoehr, PhD, is a professor in the physician assistant program at Midwestern University, Glendale, Arizona
| | - Bhupin Butaney
- Eve B. Hoover, DMSc, PA-C, is an assistant professor in the physician assistant program at Midwestern University, Glendale, Arizona
- Bhupin Butaney, PhD, is an associate professor in the clinical psychology program at Midwestern University, Glendale, Arizona
- James D. Stoehr, PhD, is a professor in the physician assistant program at Midwestern University, Glendale, Arizona
| | - James D Stoehr
- Eve B. Hoover, DMSc, PA-C, is an assistant professor in the physician assistant program at Midwestern University, Glendale, Arizona
- Bhupin Butaney, PhD, is an associate professor in the clinical psychology program at Midwestern University, Glendale, Arizona
- James D. Stoehr, PhD, is a professor in the physician assistant program at Midwestern University, Glendale, Arizona
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Lamiani G, Dordoni P, Vegni E, Barajon I. Caring for Critically Ill Patients: Clinicians' Empathy Promotes Job Satisfaction and Does Not Predict Moral Distress. Front Psychol 2020; 10:2902. [PMID: 31969851 PMCID: PMC6960200 DOI: 10.3389/fpsyg.2019.02902] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 12/06/2019] [Indexed: 12/30/2022] Open
Abstract
Background Several studies have highlighted the benefits of empathy in healthcare settings. A correlation between clinicians' empathy and patients' adherence and satisfaction, as well as the ability for the clinician to accurately assess family members' needs, has been found. However, empathy is often seen by clinicians as a risk factor for their wellbeing. This study aims to assess whether the level of empathy of clinicians working in critical care settings may expose them to moral distress, poor job satisfaction, and intention to quit their job. Methods Italian clinicians who attended the 2016 "Smart Meeting Anesthesia Resuscitation in Intensive Care" completed the Empathy Quotient questionnaire, the Moral Distress Scale-Revised, and two questions assessing job satisfaction and intention to quit the job. Multiple linear and logistic regressions were performed to determine if clinicians' empathy influences moral distress, job satisfaction, and intention to quit. Age, gender, and profession were used as control variables. Results Out of 927 questionnaires distributed, 216 were returned (23% response rate) and 210 were used in the analyses. Respondents were 56% physicians, 24% nurses, and 20% residents. Over half of the clinicians (58%) were female. Empathy resulted the only significant predictor of job satisfaction (β = 0.193; p < 0.05). None of the variables included in the model predicted moral distress. Conclusion Empathy determined neither moral distress nor intention to quit. Findings suggest that empathy is not a risk factor for critical care clinicians in developing moral distress and the intention to quit their job. On the contrary, empathy was found to enhance clinicians' job satisfaction.
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Affiliation(s)
- Giulia Lamiani
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Paola Dordoni
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy.,Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
| | - Elena Vegni
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Isabella Barajon
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Lilly CM, Mickelson JT. Evolution of the Intensive Care Unit Telemedicine Value Proposition. Crit Care Clin 2019; 35:463-477. [PMID: 31076046 DOI: 10.1016/j.ccc.2019.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Advances in clinical information sciences, telecommunication technologies, electronic health records, early warning systems, automated acuity assessment, and clinician communication support systems have allowed current-generation intensive care (ICU) telemedicine systems to address the inefficiencies of the failed advice-upon-request ICU telemedicine model. Value is related to the ability of health care systems to leverage ICU telemedicine resources to provide care. Local financial benefits of ICU telemedicine program implementation depend on changing behavior to better focus on activities that reduce the duration of critical illness and length of stay.
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Affiliation(s)
- Craig M Lilly
- Department of Medicine, University of Massachusetts Medical School, Graduate School of Biomedical Sciences, UMass Memorial Health Care, Memorial Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA; Department of Anesthesiology, and Surgery, Clinical and Population Health Research Program, University of Massachusetts Medical School, Graduate School of Biomedical Sciences, UMass Memorial Health Care, Memorial Medical Center, 281 Lincoln Street, Worcester, MA 01605, USA.
| | - Jared T Mickelson
- Department of Medicine, University of Massachusetts Medical School, Graduate School of Biomedical Sciences, UMass Memorial Health Care, Memorial Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA
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Mignot A, Wilhelm MC, Valette A, Gavard-Perret ML, Abord-De-Chatillon E, Epaulard O. Behavior of nurses and nurse aides toward influenza vaccine: the impact of the perception of occupational working conditions. Hum Vaccin Immunother 2019; 16:1125-1131. [PMID: 31809633 DOI: 10.1080/21645515.2019.1694328] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Although influenza vaccination of hospital healthcare workers (HCWs) has been associated with a reduction in patient mortality and morbidity, HCW vaccine coverage is low in France. Previous studies identified the role of perceptions of vaccine efficacy and safety as well as practical issues (e.g., limited time). We aimed to determine whether HCW behavior toward influenza vaccine was associated with occupation-related psycho-social issues and perceptions of management. Between February and August 2018, an anonymous online questionnaire explored the perceptions and behavior of nurses and nurse aides regarding the influenza vaccine, as well as the perceived quality of professional management, perceived psychological contract breach, perceived workload, and compassion fatigue using previously validated scales. Among the 791 respondents (mean age 36.9 ± 10 years, female 85.0%; nurses 76.4%), 28.6% had been vaccinated during the current year (i.e., the study year) and 13.0% during the previous year. Among those not vaccinated during the study year, their vaccination intention for the coming year on a 1-5 scale was 1/5 for 68.5% and 5/5 for 15.4%. Positive behavior/intention regarding the influenza vaccine (recent vaccination and/or high future intention) was positively correlated with perceptions of management and negatively correlated with feelings of a psychological contract breach and compassion fatigue. In multivariate analysis, this positive behavior/intention was correlated with management perception independently of the perceptions of vaccination itself. Among nurses and nurse aides, the propensity to be vaccinated appears to depend closely on the perceived working conditions. These factors should be addressed when promoting vaccination among these populations.
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Affiliation(s)
- Alexandre Mignot
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France.,Fédération d'infectiologie multidisciplinaire de l'Arc Alpin, Université Grenoble Alpes, Grenoble, France
| | - Marie-Claire Wilhelm
- CNRS, Grenoble Institute of Engineering, CERAG, Université Grenoble Alpes, Grenoble, France
| | - Annick Valette
- CNRS, Grenoble Institute of Engineering, CERAG, Université Grenoble Alpes, Grenoble, France
| | | | - Emmanuel Abord-De-Chatillon
- CNRS, Grenoble Institute of Engineering, CERAG, Université Grenoble Alpes, Grenoble, France.,LEST, CNRS, Aix-Marseille Université, Aix en Provence, France
| | - Olivier Epaulard
- Service de Maladies Infectieuses, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France.,Fédération d'infectiologie multidisciplinaire de l'Arc Alpin, Université Grenoble Alpes, Grenoble, France
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Deffner T, Schwarzkopf D, Waydhas C. [Psychological care in German intensive care units : Results of a survey among the members of the German Interdisciplinary Association for Intensive Care and Emergency Medicine]. Med Klin Intensivmed Notfmed 2019; 116:146-153. [PMID: 31781828 DOI: 10.1007/s00063-019-00638-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/22/2019] [Accepted: 11/02/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Psychological care should be provided in intensive care units (ICUs) because of the proven mental symptoms of patients and relatives. Even physicians and nurses can benefit from a corresponding care structure. Knowledge is lacking whether and how psychological care for patients and relatives as well as support for staff in German ICUs is implemented. For this reason, a survey was conducted among the members of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) to gain an overview of the current structures and the need for psychological support. METHODS The members of DIVI were invited to participate in a web-based survey. A total of 226 physicians and nurses took part in the survey. Analysis included statistics and group comparisons with Χ2 methods. RESULTS In all care areas, psychological care of patients, relatives, and support for staff, respondents indicated a significant undersupply and expressed the need for improved care. A model which provides consular or team-integrated support based on the level of care is conceivable. DISCUSSION The current state of psychological care in German ICUs does not cover the existing need. Consequently the development of concepts and the beginning of discussions on how appropriate psychological care can be implemented in the future is necessary.
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Affiliation(s)
- T Deffner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Jena, Deutschland.
- Kinderklinik, Sektion Neonatologie und Pädiatrische Intensivmedizin, Universitätsklinikum Jena, Jena, Deutschland.
| | - D Schwarzkopf
- Center for Sepsis Control and Care, Universitätsklinikum Jena, Jena, Deutschland
| | - C Waydhas
- Chirurgische Universitätsklinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland
- Medizinische Fakultät, Universität Duisburg-Essen, Duisburg, Deutschland
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96
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Abstract
RATIONALE Caring for patients at the end of life is emotionally taxing and may contribute to burnout. Nevertheless, little is known about the factors associated with emotional distress in intensive care unit (ICU) nurses. OBJECTIVES To identify patient and family factors associated with nurses' emotional distress in caring for dying patients in the ICU. METHODS One hundred nurses who cared for 200 deceased ICU patients at two large academic medical centers in the Northeast United States were interviewed about patients' psychological and physical symptoms, their reactions to those patient experiences (e.g., emotional distress), and perceived factors contributing to their emotional distress. Logistic regression analyses modeled nurses' emotional distress as a function of patient symptoms and care. RESULTS Patients' overall quality of death (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.31-7.25), suffering (OR, 2.34; CI, 1.03-5.29), and loss of dignity (OR, 2.95; CI, 1.19-7.29) were significantly associated with nurse emotional distress. Some 40.5% (79 of 195) of nurses identified families' fears of patient death, and 34.4% (67 of 195) identified families' unrealistic expectations as contributing to their own emotional distress. CONCLUSIONS Patients' emotional distress, physical distress, and perceived quality of death are associated with nurse emotional distress. Unrealistic family expectations for the patient may be a source of nurse emotional distress. Improving patients' quality of death, including enhancing their dignity, reducing their suffering, and promoting acceptance of an impending death among family members may improve the emotional health of nurses.
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97
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Dow AW, Baernholdt M, Santen SA, Baker K, Sessler CN. Practitioner wellbeing as an interprofessional imperative. J Interprof Care 2019; 33:603-607. [DOI: 10.1080/13561820.2019.1673705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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98
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Morales CL, Brown MM. Creating a Care for the Caregiver Program in a Ten-Hospital Health System. Crit Care Nurs Clin North Am 2019; 31:461-473. [PMID: 31685112 DOI: 10.1016/j.cnc.2019.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Critical care clinicians involved serious adverse events may experience a constellation of distressing emotions that may interfere with home and work life. Offering support after a serious adverse event may restore a clinician's ability to cope with the event, reestablish emotional balance and assist a clinician to function capably in the workplace and at home. A description of a care for the caregiver program implementation at a 10-hospital health system provides a roadmap to implement this program in other hospitals and health systems.
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Affiliation(s)
- Crystal L Morales
- High Reliability and Safety, Medstar Institute for Quality and Safety, 3007 Tilden Street, Northwest, Suite 5N, Washington, DC 20008, USA
| | - Mary-Michael Brown
- Nursing Practice Innovation, Medstar Health, 10980 Grantchester Place, 6101, Columbia, MD 21044, USA.
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99
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Update and recommendations in decision making referred to limitation of advanced life support treatment. Med Intensiva 2019; 44:101-112. [PMID: 31472947 DOI: 10.1016/j.medin.2019.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/16/2019] [Accepted: 07/14/2019] [Indexed: 12/18/2022]
Abstract
The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit.
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100
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Colville GA, Dawson D, Rabinthiran S, Chaudry-Daley Z, Perkins-Porras L. A survey of moral distress in staff working in intensive care in the UK. J Intensive Care Soc 2019; 20:196-203. [PMID: 31447911 PMCID: PMC6693114 DOI: 10.1177/1751143718787753] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Elevated rates of burnout and post-traumatic stress have been found in staff working in critical care settings, but the aspect of moral distress has been harder to quantify until a recent revision of a scale previously designed for nurses, was adapted for use with a range of health professionals, including physicians. In this cross-sectional survey, n = 171 nurses and physicians working in intensive care in the United Kingdom completed the Moral Distress Scale-Revised in relation to their experiences at work. Mean (SD) Moral Distress Scale-Revised score was 70.2 (39.6). Significant associations were found with female gender (female 74.1 (40.2) vs. male 55.5 (33.8), p = 0.010); depression (r = 0.165, p = 0.035) and with intention to leave job (considering leaving 85.5 (42.4) vs. not considering leaving 67.2 (38.6), p = 0.040). These results highlight the importance of considering the moral impact of work-related issues when addressing staff wellbeing in critical care settings.
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Affiliation(s)
- GA Colville
- Paediatric Psychology Service, St
George’s University Hospitals NHS Foundation Trust, London, UK
- Population Health Research Institute, St
George's, University of London, UK
| | - D Dawson
- Adult Intensive Care Units, St George’s
University Hospitals NHS Foundation Trust, London, UK
| | - S Rabinthiran
- Medical School, St George’s, University
of London, UK
| | | | - L Perkins-Porras
- Institute of Medical and Behavioural
Education, St George’s, University of London, UK
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