A Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Health-care Professionals. A Call for Action

PERSonality, Ehical, and PROfessional quality of life in Pediatric/Adult Intensive Nurses study: PERSEPRO PAIN study

BACKGROUND

The World Health Organization included burnout syndrome criteria that reduce both professional quality of life and work satisfaction in its 11th Revision of the International Classification of Diseases in 2019 while nursing bodies have issued action calls to prevent burnout syndrome. Despite this, the effect of social factors, personality traits and cross-interaction on professional quality of life is still unclear.

AIM

To reveal the association between ethical climate, personal trait and professional quality of life.

METHOD

An online survey of registered nurses working in adult, pediatric or both ICUs. We used the ten-item personality measure based on The Big Five theory and Type-D personality Scale-14 then measured the ethical climate with the Hospital Ethical Climate Survey and the professional domains of burnout syndrome, secondary traumatic stress and compassion satisfaction by the Professional Quality of Life Scale Version 5 simultaneously. Multivariate analysis confirmed the triangular association of hospital ethical climate, personality traits and professional quality of life.

RESULT

We enrolled 310 participants from September 2019 to February 2020. Mean age was 33.1 years (± 5.9) and about 70% were female. In the multivariate analysis, neuroticism (p = 0.03, p = 0.01) and Type D personality (both of p<0.01) were associated with burnout syndrome and secondary traumatic stress while agreeableness (p<0.01) was associated with secondary traumatic stress. Conversely, extraversion (p = 0.01), agreeableness (p<0.01) and openness (p<0.01) were associated with compassion satisfaction. We also observed interactions between hospital ethical climate and conscientiousness (p = 0.01) for burnout syndrome and secondary traumatic stress. Neuroticism was related to (p<0.01) BOS and compassion satisfaction while Type D personality (p<0.01) correlated with burnout syndrome and secondary traumatic stress.

CONCLUSION

Hospital ethical climate strongly affects professional quality of life in nurses with specific personality traits. Therefore, it is important to maintain an ethical hospital climate, considering individual personalities to prevent burnout syndrome.

Evaluating a psychological support service focused on the needs of critical care and theatres staff in the first wave of COVID-19

BACKGROUND

In response to COVID-19, the authors used clinical psychology resources from their hospital's Pain Medicine Department to provide direct support to critical areas.

AIMS

The degree to which the service met the needs of staff and managers between March and August 2020 was evaluated.

METHODS

A total of 51 staff were referred. Most were nurses (43%), followed by theatre practitioners (36%), healthcare assistants (9%), consultants (8%), administrative (2%) and support staff (2%). Working status, reason for referral and presenting difficulties at first appointment and outcome were recorded. Staff were sent an anonymous survey following intervention.

FINDINGS

Staff reported high rates of burnout, anxiety and low mood, with 22% experiencing exacerbation of pre-existing mental health problems. All staff reported benefit from the intervention and managers provided positive feedback.

CONCLUSION

Establishing a supportive service that included psychology benefited both staff and managers at the peak of the pandemic. Recommendations are provided.

Clinicians’ Social Support, Job Stress, and Intent to Leave Healthcare during COVID-19

The onset of COVID-19 has escalated healthcare workers’ psychological distress. Multiple factors, including prolonged exposure to COVID-19 patients, irregular working hours, and workload, have substantially contributed to stress and burnout among healthcare workers. To explore the impact of COVID-19 on healthcare workers, our study compares the job stress, social support, and intention to leave the job among healthcare workers working in a pandemic (H_P) and a non-pandemic hospital (H_NP) in Turkey during the pandemic. The cross-sectional, paper-based survey involved 403 healthcare workers including physicians, registered nurses, health technicians, and auxiliary staff across two hospitals from 1 September 2020 to 31 November 2020. The findings indicate a significant impact of ‘Job stress’ on ‘Intent to leave’ job among participants in the H_P. We noted that ‘intent to leave’ and ‘job stress’ were significantly higher among the H_P healthcare workers than those working in the H_NP, respectively. However, workers’ ‘social support’ was significantly lower in the H_P. Healthcare workers, during COVID-19, face several hurdles such as job stress, reduced social support, and excessive workload, all of which are potential factors influencing a care provider’s intent to leave the job.

Experiences of Black and Latinx health care workers in support roles during the COVID-19 pandemic: A qualitative study

Black and Latinx individuals, and in particular women, comprise an essential health care workforce often serving in support roles such as nursing assistants and dietary service staff. Compared to physicians and nurses, they are underpaid and potentially undervalued, yet play a critical role in health systems. This study examined the impact of the coronavirus disease 2019 (COVID-19) pandemic from the perspective of Black and Latinx health care workers in support roles (referred to here as HCWs). From December 2020 to February 2021, we conducted 2 group interviews (n = 9, 1 group in English and 1 group in Spanish language) and 8 individual interviews (1 in Spanish and 7 in English) with HCWs. Participants were members of a high-risk workforce as well as of communities that suffered disproportionately during the pandemic. Overall, they described disruptive changes in responsibilities and roles at work. These disruptions were intensified by the constant fear of contracting COVID-19 themselves and infecting their family members. HCWs with direct patient care responsibilities reported reduced opportunities for personal connection with patients. Perspectives on vaccines reportedly changed over time, and were influenced by peers' vaccination and information from trusted sources. The pandemic has exposed the stress endured by an essential workforce that plays a critical role in healthcare. As such, healthcare systems need to dedicate resources to improve the work conditions for this marginalized workforce including offering resources that support resilience. Overall working conditions and, wages must be largely improved to ensure their wellbeing and retain them in their roles to manage the next public health emergency. The role of HCWs serving as ambassadors to provide accurate information on COVID-19 and vaccination among their coworkers and communities also warrants further study.

Artificial intelligence–aided diagnosis model for acute respiratory distress syndrome combining clinical data and chest radiographs

Objective

The aim of this study was to develop an artificial intelligence–based model to detect the presence of acute respiratory distress syndrome (ARDS) using clinical data and chest X-ray (CXR) data.

Method

The transfer learning method was used to train a convolutional neural network (CNN) model with an external image dataset to extract the image features. Then, the last layer of the model was fine-tuned to determine the probability of ARDS. The clinical data were trained using three machine learning algorithms—eXtreme Gradient Boosting (XGB), random forest (RF), and logistic regression (LR)—to estimate the probability of ARDS. Finally, ensemble-weighted methods were proposed that combined the image model and the clinical data model to estimate the probability of ARDS. An analysis of the importance of clinical features was performed to explore the most important features in detecting ARDS. A gradient-weighted class activation mapping (Grad-CAM) model was used to explain what our CNN sees and understands when making a decision.

Results

The proposed ensemble-weighted methods improved the performances of the ARDS classifiers (XGB + CNN, area under the curve [AUC] = 0.916; RF + CNN, AUC = 0.920; LR + CNN, AUC = 0.920; XGB + RF + LR + CNN, AUC = 0.925). In addition, the ML model using clinical data to present the top 15 important features to identify the risk factors of ARDS.

Conclusion

This study developed combined machine learning models with clinical data and CXR images to detect ARDS. According to the results of the Shapley Additive exPlanations values and the Grad-CAM techniques, an explicable ARDS diagnosis model is suitable for a real-life scenario.

Lived experiences of healthcare workers on the front line during the COVID-19 pandemic: a qualitative interview study

OBJECTIVES

This study aimed to investigate the presence of perceived stressors, psychological safety and teamwork in healthcare professionals. As the timeframe for this study spanned the first wave of the COVID-19 pandemic, data were captured demonstrating the impact of the pandemic on these factors.

DESIGN

Qualitative interview study.

SETTING

All staff working within the emergency and critical care departments of one National Health Service Trust in London, UK.

PARTICIPANTS

Forty-nine participants were recruited using a purposive sampling technique and interviewed when the first wave of the COVID-19 pandemic had subsided.

MAIN OUTCOME MEASURES

Evaluation of changes in perceived stressors, psychological safety and teamwork in individuals working during the COVID-19 pandemic.

RESULTS

The thematic analysis relating to a participant's lived experiences while working during COVID-19 led to the construction of five key themes, including 'psychological effects' and 'changes in team dynamics'. Several psychological effects were described, including the presence of psychological distress and insights into the aetiology of moral injury. There was marked heterogeneity in participants' response to COVID-19, particularly with respect to changes in team dynamics and the perception of a psychologically safe environment. Descriptions of improved team cohesiveness and camaraderie contrasted with stories of new barriers, notably due to the high workload and the impact of personal protective equipment. Building on these themes, a map of key changes arising due to the pandemic was developed, highlighting potential opportunities to provide targeted support.

CONCLUSIONS

Working on the front line of a pandemic can have significant implications for healthcare workers, putting them at risk of psychological distress and moral injury, as well as affecting team dynamics. There is striking heterogeneity in the manifestation of these challenges. Team leaders can use the themes and qualitative data from this study to help identify areas for management focus and individual and team support.

The Mediating Role of Gender, Age, COVID-19 Symptoms and Changing of Mansion on the Mental Health of Healthcare Workers Operating in Italy during the First Wave of the COVID-19 Pandemic

The COVID-19 pandemic has tested the performance of hospitals and intensive care units around the world. Health care workers (HCWs) have been used to developmental symptoms, but this was especially true during the COVID-19 pandemic when HCWs have been faced with many other sources of stress and anxiety that can usually be avoided. Moreover, long-term shifts and unprecedented population restrictions have weakened people’s ability to cope with stress. The research aims to observe the dynamic interplay between burnout, depression, distress, and anxiety in HCWs working in various settings, with specific a focus on emotional exhaustion, depersonalization, and a diminished sense of personal achievement in mediating a worse mental health status during the first wave of the COVID-19 pandemic in Italy. We performed a mediation analysis, which resulted in a strong correlation among depression, psychological distress, health perception and anxiety, and the impact of job burnout on anxiety, depression, and distress. Gender seemed to have a strong correlation with burnout, anxiety, and distress; the impact of the COVID-19 pandemic on Quality of Life seemed to affect anxiety and depression; the possible changes in job tasks and duties (intended as a change in work area or location and role change)influenced depression and job burnout. Encouraging supportive and educational strategies would be recommended to policymakers.

Who am I? Narratives as a window to transformative moments in critical care

Critical care clinicians practice a liminal medicine at the border between life and death, witnessing suffering and tragedy which cannot fail to impact the clinicians themselves. Clinicians' professional identity is predicated upon their iterative efforts to articulate and contextualize these experiences, while a failure to do so may lead to burnout. This journey of self-discovery is illuminated by clinician narratives which capture key moments in building their professional identity. We analyzed a collection of narratives by critical care clinicians to determine which experiences most profoundly impacted their professional identity formation. After surveying 30 critical care journals, we identified one journal that published 84 clinician narratives since 2013; these constituted our data source. A clinician educator, an art historian, and an anthropologist analyzed these pieces using a narrative analysis technique identifying major themes and subthemes. Once the research team agreed on a thematic structure, a clinician-ethicist and a trainee read all the pieces for analytic validation. The main theme that emerged across all these pieces was the experience of existing at the heart of the dynamic tension between life and death. We identified three further sub-themes: the experience of bridging the existential divide between dissimilar worlds and contexts, fulfilling divergent roles, and the concurrent experience of feeling dissonant emotions. Our study constitutes a novel exploration of transformative clinical experiences within Critical Care, introducing a methodology that equips medical educators in Critical Care and beyond to better understand and support clinicians in their professional identity formation. As clinician burnout soars amidst increasing stressors on our healthcare systems, a healthy professional identity formation is an invaluable asset for personal growth and moral resilience. Our study paves the way for post-graduate and continuing education interventions that foster mindful personal growth within the medical subspecialties.

Identification and assessment of nursing task errors in emergency department using SHERPA technique and offering remedial strategies

BACKGROUND

Improving health care quality is a global concern, and providing patients with safe healthcare is a WHO Patient Safety priority. The technological revolution in health services has highlighted the role of human factors in committing such errors, and since the number of medical errors, including nursing errors, increases on a daily basis.

OBJECTIVES

This research aimed to identify the causes of Nursing Task Errors in Emergency Department Using SHERPA Technique and adopt strategies to prevent and reduce them. Participants were 47 nurses (24 women and 23 men), who worked morning, evening and night shifts. The nurses were taught the methodology and talked about the objective of the study; they were then interviewed and observed for six months while working. This way, their tasks and subtasks were demarcated and the Hierarchical Task Analysis (HTA) was performed. SHERPA Error Mode Checklist was used to identify errors and their various types and then risk assessment was conducted.

RESULTS

A total of 45 tasks, 234 subtasks, and 326 errors in regard to nursing activities were identified in the emergency department, with the highest frequency for action errors (61.34%) and the lowest for communication errors (1.84%). Also, there were 7.24 errors per task. The highest and lowest number of errors were at the 'unfavorable' (19.07%) and,'acceptable (safe)' (6.15%) risk levels, respectively. Based on the finding staff training, workload elimination,work process modification and updating guidelines are recommended.

CONCLUSION

The results of present study were also submitted to the University Medical Executive management Committee to make individual, educational and organizational reforms (guidelines and instructions) in order to optimize the situation.

Understanding and mitigating moral injury in nurses

Moral injury may be experienced when a person perpetrates, witnesses or fails to prevent an act that conflicts with their moral values and beliefs. The concept of moral injury has its origins in the context of military personnel encountering ethically challenging decisions during armed conflict. The term has been applied to healthcare and moral injury is increasingly acknowledged to be a challenge for healthcare professionals. Nurses across all specialties and settings are frequently required to make or witness ethically challenging decisions about patient care. The coronavirus disease 2019 (COVID-19) pandemic has increased nurses' risk of sustaining moral injury. This article discusses the manifestations of moral injury and its associated risk factors, including the effects of the COVID-19 pandemic. It also outlines various strategies that can be used to mitigate and/or prevent moral injury in nurses.

The Influence of the COVID-19 Pandemic on ICU Organization, Care Processes, and Frontline Clinician Experiences: A Qualitative Study

BACKGROUND

The COVID-19 pandemic resulted in unprecedented adjustments to ICU organization and care processes globally.

RESEARCH QUESTIONS

Did hospital emergency responses to the COVID-19 pandemic differ depending on hospital setting? Which strategies worked well to mitigate strain as perceived by intensivists?

STUDY DESIGN AND METHODS

Between August and November 2020, we carried out semistructured interviews of intensivists from tertiary and community hospitals across six regions in the United States that experienced early or large surges of COVID-19 patients, or both. We identified themes of hospital emergency responses using the four S framework of acute surge planning: space, staff, stuff, system.

RESULTS

Thirty-three intensivists from seven tertiary and six community hospitals participated. Clinicians across both settings believed that canceling elective surgeries was helpful to increase ICU capabilities and that hospitals should establish clearly defined thresholds at which surgeries are limited during future surge events. ICU staff was the most limited resource; staff shortages were improved by the use of tiered staffing models, just-in-time training for non-ICU clinicians, designated treatment teams, and deployment of trainees. Personal protective equipment (PPE) shortages and reuse were widespread, causing substantial distress among clinicians; hands-on PPE training was helpful to reduce clinicians' anxiety. Transparency and involvement of frontline clinicians as stakeholders were important components of effective emergency responses and helped to maintain trust among staff.

INTERPRETATION

We identified several strategies potentially to mitigate strain as perceived by intensivists working in both tertiary and community hospital settings. Our study also demonstrated the importance of trust and transparency between frontline staff and hospital leadership as key components of effective emergency responses during public health crises.

Psychological impact of caring for critically ill patients during the Covid-19 pandemic and recommendations for staff support

BACKGROUND

Reports of significant psychological stress among frontline healthcare workers are emerging from the Covid-19 outbreak in China. Concerningly, these match findings from previous infective outbreaks, which resulted in long-term psychological pathology.

METHODS

During the Covid-19 pandemic, a multi-disciplinary cohort of Intensive Care staff completed an online survey of psychological well-being and rated the perceived usefulness of supportive interventions.

RESULTS

Sixty per cent of invited staff responded. Seventy-seven per cent reported normal/high level of resilience. Thirty-two staff (35%) reported anxiety of a level at which formal psychological assessment is recommended. Sixteen (14%) staff members reported symptomology suggestive of post-traumatic stress disorder (PTSD). Multiple regression analysis revealed a significant relationship between job-related well-being, anxiety (p = 0.003) and PTSD (p = 0.005). Nurses were seven times more likely than doctors to score higher anxiety (OR = 6.8; p = 0.01). Preferred supportive interventions were adequate personal protective equipment, rest facilities and regular breaks. In the subgroup with high anxiety, psychological support was perceived as significantly more useful, with significant reductions reported for rest facilities and PPE.

DISCUSSION

We report concerning levels of anxiety and post-traumatic stress symptomology among intensive care staff during the Covid-19 crisis, significantly impacting job-related well-being. Nurses are disproportionately affected. Overall, physiologically protective supportive interventions were preferred by staff; however, staff with established anxiety desire professional psychological help. Our findings match reports from SARS 2003 and China 2019. To mitigate long-term psychological consequences of caring for patients during a pandemic, easily deliverable protective strategies should be instigated, supported by formal and longer-term psychological support. Particular attention should be paid to developing strategies which support nursing staff.

Staff wellbeing in times of COVID-19

In the last 10 years, there has been increasing interest into the psychological wellbeing of healthcare providers. Within critical care, increasing attention is being paid to the concept of 'burnout' - a cluster of symptoms that adversely affect the health of critical care providers. Publications and statements from the major critical care societies have all addressed this syndrome and emphasised urgency in tackling it. The current COVID-19 pandemic has fundamentally changed the way we work, communicate and learn. Even before the pandemic, there have been growing concerns and acknowledgement that healthcare practitioners in intensive care are at increased risk of burnout and burnout syndrome. There has never been greater pressure on intensive care or indeed healthcare as a whole to look after so many patients during this pandemic and yet there is global acknowledgement that key to overcoming these challenges is to look after the care providers - both physically and psychologically. In this paper, we review the issue of burnout amongst healthcare practitioners during current pandemic. We present the impact of burnout on the individual and the system as a whole but perhaps most importantly, we provide a review of steps being taken to mitigate against these adverse outcomes in the short and longer term.

Exploring factors which contribute to the resilience of nurses working in the neonatal care unit: A grounded theory study

OBJECTIVES

This study aimed to produce a theoretical model to understand factors which affect the resilience of neonatal nurses. Nurses experience high levels of burnout due to the occupational stress they are exposed to. Burnout negatively affects both staff and patient outcomes, and in this population would likely affect the establishment of crucial early caregiver-infant relationships in the neonatal unit. Research suggests that increasing nurses' resilience can protect them against burnout, thus understanding factors that affect resilience in this population is critical.

RESEARCH METHODOLOGY

The study adopted a constructivist grounded theory design.

SETTING AND PARTICIPANTS

All participants were qualified registered nurses employed on a permanent basis in a Level 3 neonatal unit. Thirteen registered nurses attended one individual semi-structured interview. A constructivist grounded theory approach was used to analyse the subsequent verbatim transcripts.

FINDINGS

The resulting model identified that individuals working as nurses in the neonatal unit function within different systemic contexts: the nursing team; the family unit; the broader neonatal team; the National Health Service and their world outside the unit. Each context presents different practical, emotional and ethical challenges. These challenges are navigated through a combination of contextual, interpersonal and intrapersonal strategies.

CONCLUSIONS

The model is contextually embedded and extends existing literature pertaining to resilience of healthcare staff in other contexts. Suggestions are made in terms of adaptations to the organisational, social and individual contexts to benefit nursing resilience. Implications of the findings are also considered within the context of the ongoing Covid-19 pandemic.

Research Needs for Inpatient Management of Severe Alcohol Withdrawal Syndrome: An Official American Thoracic Society Research Statement

Background: Severe alcohol withdrawal syndrome (SAWS) is highly morbid, costly, and common among hospitalized patients, yet minimal evidence exists to guide inpatient management. Research needs in this field are broad, spanning the translational science spectrum. Goals: This research statement aims to describe what is known about SAWS, identify knowledge gaps, and offer recommendations for research in each domain of the Institute of Medicine T0-T4 continuum to advance the care of hospitalized patients who experience SAWS. Methods: Clinicians and researchers with unique and complementary expertise in basic, clinical, and implementation research related to unhealthy alcohol consumption and alcohol withdrawal were invited to participate in a workshop at the American Thoracic Society 2019 International Conference. The committee was subdivided into four groups on the basis of interest and expertise: T0-T1 (basic science research with translation to humans), T2 (research translating to patients), T3 (research translating to clinical practice), and T4 (research translating to communities). A medical librarian conducted a pragmatic literature search to facilitate this work, and committee members reviewed and supplemented the resulting evidence, identifying key knowledge gaps. Results: The committee identified several investigative opportunities to advance the care of patients with SAWS in each domain of the translational science spectrum. Major themes included 1) the need to investigate non-γ-aminobutyric acid pathways for alcohol withdrawal syndrome treatment; 2) harnessing retrospective and electronic health record data to identify risk factors and create objective severity scoring systems, particularly for acutely ill patients with SAWS; 3) the need for more robust comparative-effectiveness data to identify optimal SAWS treatment strategies; and 4) recommendations to accelerate implementation of effective treatments into practice. Conclusions: The dearth of evidence supporting management decisions for hospitalized patients with SAWS, many of whom require critical care, represents both a call to action and an opportunity for the American Thoracic Society and larger scientific communities to improve care for a vulnerable patient population. This report highlights basic, clinical, and implementation research that diverse experts agree will have the greatest impact on improving care for hospitalized patients with SAWS.

Employment and working conditions of nurses: where and how health inequalities have increased during the COVID-19 pandemic?

BACKGROUND

Nurses and midwives play a critical role in the provision of care and the optimization of health services resources worldwide, which is particularly relevant during the current COVID-19 pandemic. However, they can only provide quality services if their work environment provides adequate conditions to support them. Today the employment and working conditions of many nurses worldwide are precarious, and the current pandemic has prompted more visibility to the vulnerability to health-damaging factors of nurses' globally. This desk review explores how employment relations, and employment and working conditions may be negatively affecting the health of nurses in countries such as Brazil, Croatia, India, Ireland, Italy, México, Nepal, Spain, and the United Kingdom.

MAIN BODY

Nurses' health is influenced by the broader social, economic, and political system and the redistribution of power relations that creates new policies regarding the labour market and the welfare state. The vulnerability faced by nurses is heightened by gender inequalities, in addition to social class, ethnicity/race (and caste), age and migrant status, that are inequality axes that explain why nurses' workers, and often their families, are exposed to multiple risks and/or poorer health. Before the COVID-19 pandemic, informalization of nurses' employment and working conditions were unfair and harmed their health. During COVID-19 pandemic, there is evidence that the employment and working conditions of nurses are associated to poor physical and mental health.

CONCLUSION

The protection of nurses' health is paramount. International and national enforceable standards are needed, along with economic and health policies designed to substantially improve employment and working conditions for nurses and work-life balance. More knowledge is needed to understand the pathways and mechanisms on how precariousness might affect nurses' health and monitor the progress towards nurses' health equity.

Survey of Nurses' Experiences Applying The Joint Commission's Medication Management Titration Standards

BACKGROUND

Critical care nurses titrate continuous infusions of medications to achieve clinical end points. In 2017, The Joint Commission (TJC) placed restrictions on titration practice, decreasing nurses' autonomous decision-making.

OBJECTIVES

To describe the practice and perceptions of nurses regarding the 2017 TJC accreditation/regulatory standards for titration of continuous medication infusions.

METHODS

A survey of nurses' experiences titrating continuous medication infusions was developed, validated, and distributed electronically to members of the American Association of Critical-Care Nurses.

RESULTS

The content validity index for the survey was 1.0 for relevance and 0.95 for clarity. A total of 781 nurses completed the survey; 625 (80%) perceived titration standards to cause delays in patient care, and 726 (93%) experienced moral distress (mean [SD], 4.97 [2.67]; scale, 0-10). Among respondents, 33% could not comply with titration orders, 68% reported suboptimal care resulting from pressure to comply with orders, 70% deviated from orders to meet patient needs, and 84% requested revised orders to ensure compliance. Suboptimal care and delays in care significantly and strongly (regression coefficients ≥0.69) predicted moral distress.

CONCLUSIONS

Critical care nurses perceive TJC medication titration standards to adversely impact patient care and contribute to moral distress. The improved 2020 updates to the standards do not address delays and inability to comply with orders, leading to moral distress. Advocacy is indicated in order to mitigate unintended consequences of TJC medication management titration standards.

Professional Societies' Role in Addressing Member Burnout and Promoting Well-Being

Rationale: Critical care clinicians have high burnout rates. Previous studies have explored individual and organizational solutions to address burnout, but existing literature has not considered how professional societies can prevent burnout and promote member well-being. Objectives: The Critical Care Society Collaborative convened a task force to document professional society initiatives to address burnout, explore perspectives on the role of societies to address burnout, and develop recommendations that could guide critical care societies' efforts to promote well-being. Methods: We conducted a multiphase evaluation of 17 major U.S. professional societies whose members regularly work in critical care settings. We asked representatives from each society to document their existing well-being initiatives, and we conducted semistructured interviews to explore perspectives on the role of professional societies to address burnout. The task force members then met to discuss phase one and two findings to develop recommendations that could act as a roadmap to guide future society efforts. Results: All society representatives agreed that professional societies have a responsibility to address burnout, and they described various well-being initiatives that could act as examples for future efforts. We developed a roadmap with the following recommendations: 1) Acknowledge the problem of burnout; 2) Commit to supporting member well-being; 3) Create collaborations to promote well-being; 4) Educate and advocate for change; 5) Foster innovation through research; and 6) Support organizational and individual solutions. Conclusions: Our findings highlight a clear role for professional societies to address burnout and promote members' well-being.

Burnout of Physicians, Pharmacists and Nurses in the Course of the COVID-19 Pandemic: A Serbian Cross-Sectional Questionnaire Study

This research was a prospective, cross-sectional observational study of 128 health workers in the central part of the Republic of Serbia. The study surveyed health workers (physicians, pharmacists and nurses) who worked during peaks of the COVID-19 pandemic in the Republic of Serbia in June and November 2020. The Maslach Burnout Survey for Medical Personnel addresses three scales: (a) emotional exhaustion (EE) measures feelings of being emotionally overextended and exhausted by one’s work; (b) depersonalization (DP) measures an unfeeling and impersonal response toward recipients of one’s service, care treatment, or instruction; and (c) personal accomplishment (PA) measures feelings of competence and successful achievement in one’s work. Linear regression and the chi-square test were used to test a relationship between the input variables (x) and the single output variable (y). We can conclude that most health workers had a high degree of emotional exhaustion, but also a low degree of depersonalization and a high degree of sense of personal achievement. Nurses and physicians had similar answers on the pandemic during their work, but pharmacists had different answers.

Severity and prevalence of burnout syndrome in paediatric intensive care nurses: A systematic review

OBJECTIVES

The aim of this study is to identify burnout syndrome severity and prevalence in paediatric intensive care unit nurses.

DESIGN

Systematic review.

SETTING

Paediatric intensive care unit.

MAIN OUTCOME MEASURES

A librarian was consulted on methodology before the search process. MEDLINE (via PubMed), EMBASE, the Cochrane Library, CINAHL, and PsycINFO were searched for full-text studies published before September 2019 in any language. Only those observational studies exploring burnout syndrome, including paediatric intensive care unit nurses, were included. Two authors independently screened studies. We assessed the risk of bias within each study based on the Office of Health Assessment and Translation tool.

RESULT

After screening 1238 articles, we identified six studies which met the systematic review criteria. All studies included were published after 2012 and participant sample sizes were between 35 and 195 nurses. Three studies were conducted in the United States of America while the others were from the United Kingdom, Turkey and Taiwan. Prevalence of burnout syndrome in pediatric intensive care unit nurses was reported in these studies as between 42% and 77%. The assessment tools used in these studies were the (abbreviated) Maslach Burnout Inventory, Abbreviated Maslach Burnout Inventory, Occupational Burnout Inventory, and Professional Quality of Life Scale Version 5. We could not conduct a meta-analysis due to the lack of studies.

CONCLUSION

Our systematic review identifies that a low number (6 total) of relevant studies focused on burnout syndrome for pediatric intensive care unit nurses with a prevalence of burnout syndrome in paediatric intensive care unit nurses of between 42% and 77%.

Extended Reality for Enhanced Telehealth During and Beyond COVID-19: Viewpoint

The COVID-19 pandemic caused widespread challenges and revealed vulnerabilities across global health care systems. In response, many health care providers turned to telehealth solutions, which have been widely embraced and are likely to become standard for modern care. Immersive extended reality (XR) technologies have the potential to enhance telehealth with greater acceptability, engagement, and presence. However, numerous technical, logistic, and clinical barriers remain to the incorporation of XR technology into telehealth practice. COVID-19 may accelerate the union of XR and telehealth as researchers explore novel solutions to close social distances. In this viewpoint, we highlight research demonstrations of XR telehealth during the COVID-19 pandemic and discuss future directions to make XR the next evolution of remote health care.

A Descriptive Study of Resiliency and Health in Practicing Nurses

OBJECTIVES

The aim of this study was to identify the degree of resilience and self-perceived physical and mental health in practicing nurses.

BACKGROUND

Stressors and challenges of everyday demands influence resilience and well-being in acute care nurses.

METHODS

Nurses were surveyed using the Connor-Davidson Resilience Scale and PROMIS Global Health. One sample t test compared the study group to the general population mean of resiliency, physical and mental health scores. Linear regression analysis identified factors associated with resiliency.

RESULTS

Of the 859 practicing nurses in the sample, most were female and White, had a BSN or associate of science in nursing degree (55.2%, 30.0%) and more than 10 years of experience (57.1%), and worked in direct patient care (77.0%). Nurses had low resiliency (P < .0001) and physical health (P = .0037). Well-being factors included 2 or more missed days/shifts in 3 months (P < .001), thoughts of quitting (P = .003), and perceptions that workload was too much (P < .001).

CONCLUSIONS

Self-perceived physical and mental health was significantly associated with the degree of resilience.

Case study of a stepped-care psychological service for healthcare professionals working in critical care

Psychological injury is common among healthcare professionals and is expected to be further exacerbated by the current global pandemic, with the far-reaching impacts of this workplace trauma yet to be fully realised. Our Intensive Care Unit and Emergency Department sought to proactively introduce strategies that might reduce the anticipated short- and longer-term negative impact of the pandemic on staff and ultimately patients and families. Our organisation facilitated the temporary redeployment of senior psychologists to provide staff-focused support. Interventions included leader targeted training to increase the skills in this group, specifically for this situation, and site visits to allow for staff to meet with psychologists. Staff experiences of the intervention were explored through the direct observations of the psychologists leading the approach maintained through contemporaneous activity tracking records. An internal and embedded staff psychological service fosters help-seeking behaviours and is considered a desirable and acceptable model for healthcare leaders and professionals. What is known about the topic? Healthcare professionals are at increased risk of psychological distress and injury caused by the inherent stress of their role. What does this paper add? This paper provides service providers with insights into the benefits of an embedded staff psychological service to support the psychological wellbeing of healthcare professionals and teams within an Australian public health service context. What are the implications for practitioners? An embedded staff psychological service can better meet the psychological needs of healthcare professionals and teams by focusing on prevention and early intervention strategies through targeted and tailored systems, teams, and individual interventions.

Burnout Impact of COVID-19 Pandemic on Health-Care Professionals at Assiut University Hospitals, 2020

BACKGROUND

burnout syndrome is a serious and growing problem among medical staff. Its adverse outcomes not only affect health-care providers' health, but also extend to their patients, resulting in bad-quality care. The COVID-19 pandemic puts frontline health-care providers at greater risk of psychological stress and burnout syndrome.

OBJECTIVES

this study aimed to identify the levels of burnout among health-care professionals currently working at Assiut University hospitals during the COVID-19 pandemic.

METHODS

the current study adopted an online cross-sectional design using the SurveyMonkey® website for data collection. A total of 201 physicians were included and the Maslach Burnout Inventory (MBI) scale was used to assess the three burnout syndrome dimensions: emotional exhaustion, depersonalization, and reduced personal accomplishment.

RESULTS

about one-third, two-thirds, and one-quarter of the respondents had high emotional exhaustion, high depersonalization, and low personal accomplishment, respectively. Younger, resident, and single physicians reported higher burnout scores. The personal accomplishment score was significantly higher among males. Those working more than eight hours/day and dealing with COVID-19 patients had significantly higher scores.

CONCLUSION

during the COVID-19 pandemic, a high prevalence of burnout was recorded among physicians. Age, job title, working duration, and working hours/day were significant predictors for burnout syndrome subscale results. Preventive and interventive programs should be applied in health-care organizations during pandemics.

Burnout Rate and Risk Factors among Anesthesiologists in the United States

BACKGROUND

Physician burnout, widespread across medicine, is linked to poorer physician quality of life and reduced quality of care. Data on prevalence of and risk factors for burnout among anesthesiologists are limited. The objective of the current study was to improve understanding of burnout in anesthesiologists, identify workplace and personal factors associated with burnout among anesthesiologists, and quantify their strength of association.

METHODS

During March 2020, the authors surveyed member anesthesiologists of the American Society of Anesthesiologists. Burnout was assessed using the Maslach Burnout Inventory Human Services Survey. Additional survey questions queried workplace and personal factors. The primary research question was to assess rates of high risk for burnout (scores of at least 27 on the emotional exhaustion subscale and/or at least 10 on the depersonalization subscale of the Maslach Burnout Inventory Human Services Survey) and burnout syndrome (demonstrating all three burnout dimensions, consistent with the World Health Organization definition). The secondary research question was to identify associated risk factors.

RESULTS

Of 28,677 anesthesiologists contacted, 13.6% (3,898) completed the survey; 59.2% (2,307 of 3,898) were at high risk of burnout, and 13.8% (539 of 3,898) met criteria for burnout syndrome. On multivariable analysis, perceived lack of support at work (odds ratio, 6.7; 95% CI, 5.3 to 8.5); working greater than or equal to 40 h/week (odds ratio, 2.22; 95% CI, 1.80 to 2.75); lesbian, gay, bisexual, transgender/transsexual, queer/questioning, intersex, and asexual status (odds ratio, 2.21; 95% CI, 1.35 to 3.63); and perceived staffing shortages (odds ratio, 2.06; 95% CI, 1.76 to 2.42) were independently associated with high risk for burnout. Perceived lack of support at work (odds ratio, 10.0; 95% CI, 5.4 to 18.3) and home (odds ratio, 2.13; 95% CI, 1.69 to 2.69) were most strongly associated with burnout syndrome.

CONCLUSIONS

The prevalence of burnout among anesthesiologists is high, with workplace factors weighing heavily. The authors identified risk factors for burnout, especially perceived support in the workplace, where focused interventions may be effective in reducing burnout.

EDITOR’S PERSPECTIVE

Creative Arts Therapy as a Potential Intervention to Prevent Burnout and Build Resilience in Health Care Professionals

The delivery of health care is undergoing a rapid evolution that is dramatically changing the way health care professionals perform their job responsibilities. In this increasingly stressful work environment, professionals are experiencing alarming rates of burnout. Recent efforts to enhance wellness have been directed toward organizations. However, because of the nature of the work performed in intensive care units, interventions to develop individual resilience are also needed. Currently, medical centers are environments in which the emotional impact of work-related trauma is often minimized and rarely processed. Some individuals may struggle to describe or express the impact of those traumas. Through nonverbal interventions, creative arts therapy can help people access, explore, and share authentic emotion in visual, musical, physical, or written form. By reconstructing meaning through transformative methods, participants may confront, reflect, and better cope with traumatic experiences while catalyzing social support networks and deepening relational bonds in the workplace.

Addressing Burnout Syndrome From a Critical Care Specialty Organization Perspective

BACKGROUND

Health care specialty organizations are an important resource for their membership; however, it is not clear how specialty societies should approach combating stress and burnout on an organizational scale.

OBJECTIVE

To understand the prevalence of burnout syndrome in American Thoracic Society members, identify specialty-specific risk factors, and generate strategies for health care societies to combat burnout.

METHODS

Cross-sectional, mixed-methods survey in a sample of 2018 American Thoracic Society International Conference attendees to assess levels of burnout syndrome, work satisfaction, and stress.

RESULTS

Of the 130 respondents, 69% reported high stress, 38% met burnout criteria, and 20% confirmed chaotic work environments. Significant associations included sex and stress level; clinical time and at-home electronic health record work; and US practice and at-home electronic health record work. There were no significant associations between burnout syndrome and the selected demographics. Participants indicated patient care as the most meaningful aspect of work, whereas the highest contributors to burnout were workload and electronic health record documentation. Importantly, most respondents were unaware of available resources for burnout.

CONCLUSIONS

Health care specialty societies have access to each level of the health system, creating an opportunity to monitor trends, disseminate resources, and influence the direction of efforts to reduce workplace stress and enhance clinician well-being.

Positive Emotion Skills Intervention to Address Burnout in Critical Care Nurses

Critical care nurses experience high levels of workplace stress, which can lead to burnout. Many medical centers have begun offering wellness programs to address burnout in their nursing staff; however, most of these programs focus on reducing negative states such as stress, depression, and anxiety. A growing body of evidence highlights the unique, independent role of positive emotion in promoting adaptive coping in the face of stress. This article describes a novel approach for preventing burnout in critical care nurses: an intervention that explicitly aims to increase positive emotion by teaching individuals empirically supported skills. This positive emotion skills intervention has been used successfully in other populations and can be tailored for critical care nurses. Also discussed are recommendations for addressing burnout in intensive care unit nurses at both the individual and organizational levels.

Replenish at Work: An Integrative Program to Decrease Stress and Promote a Culture of Wellness in the Intensive Care Unit

Intensive care unit (ICU) nurses report some of the highest levels of stress and burnout because they are exposed to excessive workloads, end-of-life concerns, prolonged care, and ethical dilemmas. Supporting ICU staff through self-care and mindfulness programs is successful in improving stress and burnout and in promoting resilience. Addressing barriers to engaging in self-care practices and identifying unit-specific needs are important to consider when implementing wellness programs. Micro-restorative practices can alleviate immediate stress generated from patient care and provide a moment of peace in busy ICUs. Leadership and organizational support are vital in identifying the need for and promoting wellness programs.

Withholding and withdrawing treatment in pediatric intensive care. Update of the GFRUP recommendations

In 2005, the French-speaking task force on pediatric critical and emergency care [Groupe Francophone de Réanimation et d'Urgences Pédiatriques (GFRUP)] issued recommendations on withholding and withdrawing treatments in pediatric critical care. Since then, the French Public Health Code, modified by the laws passed in 2005 and 2016 and by their enactment decrees, has established a legal framework for practice. Now, 15 years later, an update of these recommendations was needed to factor in the experience acquired by healthcare teams, new questions raised by practice surveys, the recommendations issued in the interval, the changes in legislation, and a few legal precedents. The objective of this article is to help pediatric critical care teams find the closest possible compromise between the ethical principles guiding the care offered to the child and the family and compliance with current regulations and laws.

An international tool to measure perceived stressors in intensive care units: the PS-ICU scale

Background

The intensive care unit is increasingly recognized as a stressful environment for healthcare professionals. This context has an impact on the health of these professionals but also on the quality of their personal and professional life. However, there is currently no validated scale to measure specific stressors perceived by healthcare professionals in intensive care. The aim of this study was to construct and validate in three languages a perceived stressors scale more specific to intensive care units (ICU).

Results

We conducted a three-phase study between 2016 and 2019: (1) identification of stressors based on the verbatim of 165 nurses and physicians from 4 countries (Canada, France, Italy, and Spain). We identified 99 stressors, including those common to most healthcare professions (called generic), as well as stressors more specific to ICU professionals (called specific); (2) item elaboration and selection by a panel of interdisciplinary experts to build a provisional 99-item version of the scale. This version was pre-tested with 70 professionals in the 4 countries and enabled us to select 50 relevant items; (3) test of the validity of the scale in 497 ICU healthcare professionals. Factor analyses identified six dimensions: lack of fit with families and organizational functioning; patient- and family-related emotional load; complex/at risk situations and skill-related issues; workload and human resource management issues; difficulties related to team working; and suboptimal care situations. Correlations of the PS-ICU scale with a generic stressors measure (i.e., the Job Content Questionnaire) tested its convergent validity, while its correlations with the Maslach Burnout Inventory-HSS examined its concurrent validity. We also assessed the test–retest reliability of PS-ICU with intraclass correlation coefficients.

Conclusions

The perceived stressors in intensive care units (PS-ICU) scale have good psychometric properties in all countries. It includes six broad dimensions covering generic or specific stressors to ICU, and thus, enables the identification of work situations that are likely to generate high levels of stress at the individual and unit levels. For future studies, this tool will enable the implementation of targeted corrective actions on which intervention research can be based. It also enables national and international comparisons of stressors’ impact.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00846-0.

How the COVID-19 pandemic will change the future of critical care

Coronavirus disease 19 (COVID-19) has posed unprecedented healthcare system challenges, some of which will lead to transformative change. It is obvious to healthcare workers and policymakers alike that an effective critical care surge response must be nested within the overall care delivery model. The COVID-19 pandemic has highlighted key elements of emergency preparedness. These include having national or regional strategic reserves of personal protective equipment, intensive care unit (ICU) devices, consumables and pharmaceuticals, as well as effective supply chains and efficient utilization protocols. ICUs must also be prepared to accommodate surges of patients and ICU staffing models should allow for fluctuations in demand. Pre-existing ICU triage and end-of-life care principles should be established, implemented and updated. Daily workflow processes should be restructured to include remote connection with multidisciplinary healthcare workers and frequent communication with relatives. The pandemic has also demonstrated the benefits of digital transformation and the value of remote monitoring technologies, such as wireless monitoring. Finally, the pandemic has highlighted the value of pre-existing epidemiological registries and agile randomized controlled platform trials in generating fast, reliable data. The COVID-19 pandemic is a reminder that besides our duty to care, we are committed to improve. By meeting these challenges today, we will be able to provide better care to future patients.

Increasing the capacity to provide compassionate care by expanding knowledge of caring science practices at a pediatric hospital

BACKGROUND

The emotional aspects of patient care affect care givers' capacity to remain present, safe and caring. As demands increase and capacity decreases care providers are at risk for compassion fatigue (CF).

LOCAL PROBLEM

Our organization treats children with complicated diagnoses. Nurses carry a heavy emotional burden due to prolonged exposure to suffering with chronically ill children, ethical dilemmas, and an onus to also care for the parents.

METHODS

Our program highlights theory guided practices that honor the complexities of caring for others and creates opportunity for the care giver to slow down and prioritize how they care for themselves.

INTERVENTIONS

Caritas Circles, a small group intervention program, was developed to offer a deeper exploration of Jean Watson's Caring Sciences practice and theory using intentional practices to pause, be present and find peace in the midst of caring for sick children.

RESULTS

Quantitative and qualitative measures show improvement in care providers' ability to prioritize their own needs as they care for others. Care providers noted the need to have organizational support for resiliency, a connection to purpose as a care provider, and opportunity to let go of the emotional residue found in their role.

CONCLUSIONS

Organizations can no longer afford to ignore the emotional labor that care givers experience. This program highlights the need for hospitals to prioritize this type of experiential intervention and offer time during work hours where providers are honored and cared for, so they can continue to care for patients and families.

Acute and chronic sleep deprivation in residents: Cognition and stress biomarkers

OBJECTIVES

Insufficient sleep affects circadian hormonal profiles and inflammatory markers and may modulate attention, executive functioning and decision-making. Medical professionals and specifically resident physicians, who are involved in long-term nightshift schedules during their post-graduate training, are prone to acute and chronic sleep deprivation and disruption, putting them at risk for making medical errors. The aim of the study was to evaluate the impact of chronic and acute-on-chronic sleep deprivation and disruption among residents on selected physiological and cognitive measures.

METHODS

Thirty-three medical and surgical residents were evaluated twice - at baseline and after a 26-hour shift. Eighteen young attending physicians who did not engage in nightshift schedules served as controls and were evaluated once. Measures included morning cortisol and high-sensitivity C-reactive protein (hs-CRP), computerised tests of attention and behaviour, the Behaviour Rating Inventory of Executive Function, a risk-taking questionnaire and the Pittsburgh Sleep Quality Index.

RESULTS

Residents, but not attendings, reported chronic sleep disruption and deprivation. Residents at baseline exhibited reduced morning cortisol levels and elevated hs-CRP levels, compared to attendings. Residents at baseline had impaired global executive function compared to attendings. A nightshift with acute sleep deprivation further reduced residents' executive function. Residents at baseline and after a nightshift demonstrated increased impulsivity and slower processing time than attendings. Residents and attendings did not differ in risk-taking tendencies which were assessed in a separate cohort.

CONCLUSIONS

In a real-life setting, resident physicians exhibit increased low-grade systemic inflammation (hs-CRP) and impaired HPA-axis function. Their chronic sleep curtailment is associated with greater impulsivity, slower cognitive processing, and impaired executive function. Future research is warranted to understand how improving working schedule by increasing sleep duration may minimise the short-term and potential long-term risks to physicians in training.

Burnout and its correlates among nursing staff of intensive care units at a tertiary care center

Background:

Burnout syndrome has been widely reported in nursing staff. It is more pronounced in intensive care setting (up to 80%). This survey was designed to assess the prevalence of burnout and its correlates among critical care nurses.

Methods:

Anonymous questionnaire was distributed to all ICU nursing staff of a tertiary care teaching hospital. Questionnaire had 25 questions covering – demography, job characteristics, Visual Analogue Scale for stress, co-worker support, work–life balance, question for measuring burnout, job satisfaction, turnover intention, organizational commitment, for depression screening and psychosomatic symptoms. The burnout scale score was used to dichotomize into low burnout (<3) or high burnout (> = 3) group. These two groups were compared using Chi-square test, Fischer's exact test for categorical variables and independent t-test for continuous variables. Significant variables were entered in multivariate logistic regression analysis.

Results:

Out of 150 ICU nurses, 125 (83.3%) gave completely filled questionnaires which were evaluated. 47 (37.6%) participants reported experiencing high burnout. Binary logistic regression model revealed that lack of specialized ICU training (OR = 4.28, 95% CI: 1.62 to 11.34, P = 0.003), performing extra duty in last month (OR = 5.28, 95% CI: 1.90 to 14.67, P = 0.001), High physical symptoms in last 12 months (OR = 4.73, 95% CI: 1.56 to 14.36, P = 0.006) and mid-level experience (1–5 years) were significantly associated with burnout.

Conclusions:

Burnout is significantly prevalent (37.6%) among intensive care nurses. Specialized training and limiting work hours can help in mitigating this problem. High frequency of physical symptoms could be early indicators of burnout.

Balancing Demands: Determinants of Burnout Reported by Fellows in Pulmonary and Critical Care Medicine

Background: Burnout is common among physicians who care for critically ill patients and is known to contribute to worse patient outcomes. Fellows training in pulmonary and critical care medicine (PCCM) have risk factors that make them susceptible to burnout; for example, clinical environments that require increased intellectual and emotional demands with long hours. The Accreditation Council for Graduate Medical Education has recognized the increasing importance of trainee burnout and encourages training programs to address burnout. Objective: To assess factors related to training and practice that posed a threat to the well-being among fellows training in PCCM and to obtain suggestions regarding how programs can improve fellow well-being. Methods: We conducted a qualitative content analysis of data collected from a prior cross-sectional electronic survey with free-response questions of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States. Fellows were asked what factors posed a threat to their well-being and what changes their training program could implement. Responses were qualitatively coded and categorized into themes using thematic analysis. Results: A total of 427 fellows (44% of survey respondents) completed at least one free-response question. The majority of respondents (60%) identified as male and white/non-Hispanic (59%). The threats to well-being and burnout were grouped into five themes: clinical burden, individual factors, team culture, limited autonomy, and program resources. Clinical burden was the most common threat discussed by fellows. Fellows highlighted factors contributing to burnout that specifically pertained to trainees including challenging interpersonal relationships with attending physicians and limited protected educational time. Fellows proposed solutions addressing clinical care, changes at the program or institution level, and organizational culture changes to improve well-being. Conclusion: This study provides insight into factors fellows report as contributors to burnout and decreased well-being in addition to investigating fellow-driven solutions toward improving well-being. These solutions may help pulmonary, PCCM, and critical care medicine program directors better address fellow well-being in the future.