Burnout syndrome in critical care nursing staff

Prevalence and factors of intensive care unit conflicts: the conflicus study

RATIONALE

Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs.

OBJECTIVES

To record the prevalence, characteristics, and risk factors for conflicts in ICUs.

METHODS

One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries).

MEASUREMENTS AND MAIN RESULTS

Conflicts were perceived by 5,268 (71.6%) respondents. Nurse-physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing pre- and postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings.

CONCLUSIONS

Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement.

Advanced closed loops during mechanical ventilation (PAV, NAVA, ASV, SmartCare)

New modes of mechanical ventilation with advanced closed loops are now available, and in the future these could assume a greater role in supporting critically ill patients in intensive care units (ICUs) for several reasons. Two modes of ventilation--proportional assist ventilation and neurally adjusted ventilatory assist--deliver assisted ventilation proportional to the patient's effort, improving patient-ventilator synchrony. Also, a few systems that automate the medical reasoning with advanced closed-loops, such as SmartCare and adaptive support ventilation, have the potential to improve knowledge transfer by continuously implementing automated protocols. Moreover, they may improve patient-ventilator interactions and outcomes, and provide a partial solution to the forecast clinician shortages by reducing ICU-related costs, time spent on mechanical ventilation, and staff workload. Preliminary studies are promising, and initial systems are currently being refined with increasing clinical experience. A new era of mechanical ventilation should emerge with these systems.

Stressful intensive care unit medical crises: How individual responses impact on team performance

BACKGROUND

Intensive care units (ICUs) are recognized as stressful environments. However, the conditions in which stressors may affect health professionals' performance and well-being and the conditions that potentially lead to impaired performance and staff psychological distress are not well understood.

OBJECTIVES

The purpose of this study was to determine healthcare professionals' perceptions regarding the factors that lead to stress responses and performance impairments during ICU medical crises.

DESIGN

A qualitative study in a university-affiliated ICU in Canada.

METHODOLOGY

We conducted 32 individual semistructured interviews of ICU nurses, staff physicians, residents, and respiratory therapists in a university-affiliated hospital. The transcripts of the audiotaped interviews were analyzed using an inductive thematic methodology.

RESULTS

Increased workload, high stakes, and heavy weight of responsibility were recognized as common stressors during ICU crises. However, a high level of individual and team resources available to face such demands was also reported. When the patient's condition was changing or deteriorating unpredictably or when the expected resources were unavailable, crises were assessed by some team members as threatening, leading to individual distress. Once manifested, this emotional distress was strongly contagious to other team members. The ensuing collective anxiety was perceived as disruptive for teamwork and deleterious for individual and collective performance.

CONCLUSIONS

Individual distress reactions to ICU crises occurred in the presence of unexpectedly high demands unmatched by appropriate resources and were contagious among other team members. Given the high uncertainty surrounding many ICU medical crises, strategies aimed at preventing distress contagion among ICU health professionals may improve team performance and individual well-being.

Developing a team performance framework for the intensive care unit

OBJECTIVE

There is a growing literature on the relationship between teamwork and patient outcomes in intensive care, providing new insights into the skills required for effective team performance. The purpose of this review is to consolidate the most robust findings from this research into an intensive care unit (ICU) team performance framework.

DATA SOURCES

Studies investigating teamwork within the ICU using PubMed, Science Direct, and Web of Knowledge databases.

STUDY SELECTION

Studies investigating the relationship between aspects of teamwork and ICU outcomes, or studies testing factors that are found to influence team working in the ICU.

DATA EXTRACTION

Teamwork behaviors associated with patient or staff-related outcomes in the ICU were identified.

DATA SYNTHESIS

Teamwork behaviors were grouped according to the team process categories of "team communication," "team leadership," "team coordination," and "team decision making." A prototype framework explaining the team performance in the ICU was developed using these categories. The purpose of the framework is to consolidate the existing ICU teamwork literature and to guide the development and testing of interventions for improving teamwork.

CONCLUSIONS

Effective teamwork is shown as crucial for providing optimal patient care in the ICU. In particular, team leadership seems vital for guiding the way in which ICU team members interact and coordinate with others.

Impact of performance obstacles on intensive care nurses' workload, perceived quality and safety of care, and quality of working life

OBJECTIVES

To study the impact of performance obstacles on intensive care nurses' workload, quality and safety of care, and quality of working life (QWL). Performance obstacles are factors that hinder nurses' capacity to perform their job and that are closely associated with their immediate work system.

DATA SOURCES/STUDY SETTING

Data were collected from 265 nurses in 17 intensive care units (ICUs) between February and August 2004 via a structured questionnaire, yielding a response rate of 80 percent.

STUDY DESIGN

A cross-sectional study design was used. Data were analyzed by correlation analyses and structural equation modeling.

PRINCIPAL FINDINGS

Performance obstacles were found to affect perceived quality and safety of care and QWL of ICU nurses. Workload mediated the impact of performance obstacles with the exception of equipment-related issues on perceived quality and safety of care as well as QWL.

CONCLUSIONS

Performance obstacles in ICUs are a major determinant of nursing workload, perceived quality and safety of care, and QWL. In general, performance obstacles increase nursing workload, which in turn negatively affect perceived quality and safety of care and QWL. Redesigning the ICU work system to reduce performance obstacles may improve nurses' work.

Prolonging life and delaying death: the role of physicians in the context of limited intensive care resources

Critical care is in an emerging crisis of conflict between what individuals expect and the economic burden society and government are prepared to provide. The goal of critical care support is to prevent suffering and premature death by intensive therapy of reversible illnesses within a reasonable timeframe. Recently, it has become apparent that early support in an intensive care environment can improve patient outcomes. However, life support technology has advanced, allowing physicians to prolong life (and postpone death) in circumstances that were not possible in the recent past. This has been recognized by not only the medical community, but also by society at large. One corollary may be that expectations for recovery from critical illness have also become extremely high. In addition, greater numbers of patients are dying in intensive care units after having receiving prolonged durations of life-sustaining therapy. Herein lies the emerging crisis -- critical care therapy must be available in a timely fashion for those who require it urgently, yet its provision is largely dependent on a finite availability of both capital and human resources. Physicians are often placed in a troubling conflict of interest by pressures to use health resources prudently while also promoting the equitable and timely access to critical care therapy. In this commentary, these issues are broadly discussed from the perspective of the individual clinician as well as that of society as a whole. The intent is to generate dialogue on the dynamic between individual clinicians navigating the complexities of how and when to use critical care support in the context of end-of-life issues, the increasing demands placed on finite critical care capacity, and the reasonable expectations of society.

Critical illness outcomes in specialty versus general intensive care units

RATIONALE

General intensive care units (ICUs) provide care across a wide range of diagnoses, whereas specialty ICUs provide diagnosis-specific care. Risk-adjusted outcome differences across such units are unknown.

OBJECTIVES

To determine the association between specialty ICU care and the outcome of critical illness.

METHODS

We conducted a retrospective cohort study design analyzing patients admitted to 124 ICUs participating in the Acute Physiology and Chronic Health Evaluation IV from January 2002 to December 2005. We examined 84,182 patients admitted to specialty and general ICUs with an admitting diagnosis or procedure of acute coronary syndrome, ischemic stroke, intracranial hemorrhage, pneumonia, abdominal surgery, or coronary-artery bypass graft surgery. ICU type was determined by a local data coordinator at each site. Patients were classified by admission to a general ICU, a diagnosis-appropriate ("ideal") specialty ICU, or a diagnosis-inappropriate ("non-ideal") specialty ICU. The primary outcomes were in-hospital mortality and ICU length of stay.

MEASUREMENTS AND MAIN RESULTS

After adjusting for important confounders, there were no significant differences in risk-adjusted mortality between general versus ideal specialty ICUs for all conditions other than pneumonia. Risk-adjusted mortality was significantly greater for patients admitted to non-ideal specialty ICUs. There was no consistent effect of specialization on length of stay for all patients or for ICU survivors.

CONCLUSIONS

Ideal specialty ICU care appears to offer no survival benefit over general ICU care for select common diagnoses. Non-ideal specialty ICU care (i.e., "boarding") is associated with increased risk-adjusted mortality.

Qualitative research: adding drive and dimension to clinical research

Qualitative research and its methods stem from the social sciences and can be used to describe and interpret complex phenomena that involve individuals' views, beliefs, preferences, and subjective responses to places and people. Thus, qualitative research explores the many subjective factors that may influence patient outcomes, staff well-being, and healthcare quality, yet fail to lend themselves to the hypothesis-testing approach that characterizes quantitative research. Qualitative research is valuable in the intensive care unit to explore organizational and cultural issues and to gain insight into social interactions, healthcare delivery processes, and communication. Qualitative research generates explanatory models and theories, which can then serve to devise interventions, whose efficacy can be studied quantitatively. Thus, qualitative research works synergistically with quantitative research, providing new impetus to the research process and a new dimension to research findings. Qualitative research starts with conceptualizing the research question, choosing the appropriate qualitative strategy, and designing the study; rigorous methods specifically designed for qualitative research are then used to conduct the study, analyze the data, and verify the findings. The researcher is the data-collecting instrument, and the data are the participants' words and behaviors. Data coding methods are used to describe experiences, discover themes, and build theories. In this review, we outline the rationale and methods for conducting qualitative research to inform critical care issues. We provide an overview of available qualitative methods and explain how they can work in close synergy with quantitative methods. To illustrate the effectiveness of combining different research methods, we will refer to recent qualitative studies conducted in the intensive care unit.

The prevalence and impact of post traumatic stress disorder and burnout syndrome in nurses

OBJECTIVE

To determine whether post traumatic stress disorder (PTSD) and burnout syndrome (BOS) are common in nurses, and whether the co-existence of PTSD and BOS is associated with altered perceptions of work and nonwork-related activities.

METHODS

University hospital nurses were administered four validated psychological questionnaires.

RESULTS

The response rate was 41% (332/810). Twenty two percent (73/332) had symptoms of PTSD, 18% (61/332) met diagnostic criteria for PTSD, and 86% (277/323) met criteria for BOS. Ninety eight percent (59/60) of those fulfilling diagnostic criteria for PTSD were positive for BOS. When grouped into three categories: positive for PTSD and BOS (n=59), positive for BOS and negative for PTSD (n=217), and negative for both BOS and PTSD (n=46), there were significant differences in the years of employment as a nurse (P<.0001), perceptions of collaborative nursing care (P=.006), confidence in physicians (P=.01), and perception that their work impacted patient outcomes (P=.01). Nurses with BOS and PTSD were significantly more likely to have difficulty in their life outside of the work environment when compared to those with BOS alone.

CONCLUSIONS

We identified that PTSD and BOS are common in nurses and those with PTSD will almost uniformly have symptoms of BOS. Co-existence of PTSD and BOS has a dramatic effect on work and nonwork related activities and perceptions.

Practical guidance for evidence-based ICU family conferences

Because most critically ill patients lack decision-making capacity, physicians often ask family members to act as surrogates for the patient in discussions about the goals of care. Therefore, clinician-family communication is a central component of medical decision making in the ICU, and the quality of this communication has direct bearing on decisions made regarding care for critically ill patients. In addition, studies suggest that clinician-family communication can also have profound effects on the experiences and long-term mental health of family members. The purpose of this narrative review is to provide a context and rationale for improving the quality of communication with family members and to provide practical, evidence-based guidance on how to conduct this communication in the ICU setting. We emphasize the importance of discussing prognosis effectively, the key role of the integrated interdisciplinary team in this communication, and the importance of assessing spiritual needs and addressing barriers that can be raised by cross-cultural communication. We also discuss the potential value of protocols to encourage communication and the potential role of quality improvement for enhancing communication with family members. Last, we review issues regarding physician reimbursement for communication with family members within the context of the US health-care system. Communication with family members in the ICU setting is complex, and high-quality communication requires training and collaboration of a well-functioning interdisciplinary team. This communication also requires a balance between adhering to processes of care that are associated with improved outcomes and individualizing communication to the unique needs of the family.

[Shiftwork and quality of life among critical care nurses and paramedical personnel]

BACKGROUND

The need to reorganize hospital care in view of the inadequate number of staff available has led some departments to change shift hours to two 12-hour shifts daily. The impact of this organization on the quality of life (QoL) and daily life of caregivers has not been studied sufficiently.

OBJECTIVE

The objective of our study was to document the role of the type of schedule worked on QoL, fatigue, and burnout among critical care nursing and paramedical staff.

METHODS

A descriptive survey was conducted among the nurses, nurses' aides, and other paramedical staff of 3 critical care departments at the Timone Hospital Center in Marseille. Three groups were defined by the type of hours worked: 12-hour alternating night and day shifts, 10-hour nights, and 8-hour days. A booklet of questions was distributed to all staff; it contained one section that collected social, demographic, family and occupational data and another containing self-administered standardized and validated questionnaires that assessed QoL (SF36), fatigue (MFIS-5), and burnout (MBI).

RESULTS

The participation rate was 78%. The univariate analysis showed QoL was best in the group working 12-hour shifts, compared with the other 2 groups, while their levels of fatigue and burnout were similar. The multivariate approach, which sought to document the specific role of length of work shift on QoL showed that while the physical component of QoL might be influenced by number of hours worked (staff working 10-hour nights had lower QoL scores than either of the others), but the psychological component was not; only gender and duration of commute were significantly associated with QoL.

CONCLUSION

These results add yet more divergence to the already existing reports on how employees experience the length of their workday. The specific scheduling does not appear to affect either fatigue or the mental component of QoL, but does appear to affect the physical component of QoL. Other studies are necessary to validate these initial approaches.

Psychiatric aspects of organ transplantation in critical care

Intensive care unit teams are a critical part of the solid organ transplant process. The psychosocial issues involved during critical periods of transplantation are important for intensive care physicians and clinicians to understand to provide comprehensive care to transplant patients. This article provides a brief overview of transplant epidemiology, followed by a review of the psychosocial issues relevant to the phases of the transplant process. Considered are the pretransplant evaluation phase, psychiatric disorders in transplant patients, and cognitive impairments and delirium with additional issues specific to particular organs. Also covered are the side effects of immunosuppressive medications and special issues arising with living donors.

Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine

BACKGROUND

These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence.

PRINCIPAL FINDINGS

Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient's death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula.

CONCLUSIONS

End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.

Sleepiness in critical care nurses: results of a pilot study

BACKGROUND

Sleep deprivation, compounded by circadian disruptions, is a common problem in health care workers. Sleepiness in nurses has important implications for patients as well as nurses' own safety.

OBJECTIVE

The objective of the study was to assess comprehensively sleepiness levels in post-night-shift nurses.

METHODS

Post-night-shift nurses in the ICU and on general floors (medicine and surgery) were assessed using subjective (Epworth Sleepiness Scale [ESS]) and objective (Mean Sleep Latency Test [MSLT]) measures.

RESULTS

ESS was abnormal (>8) in 7 of 10 ICU nurses compared with 2 of 10 floor nurses (P < .005), and mean ESS score was also higher (8.7 +/- 3.9 vs. 5.6 +/- 2.1, respectively; P = 0.042). MSLT values for the first nap period were in the pathologic range in the ICU nurses compared with the floor nurses (4.65 +/- 5.5 vs. 10.85 +/- 7.4 minutes, respectively; P < .05).

CONCLUSIONS

Post-night-shift RNs working in the ICU have a pathologic degree of sleepiness.

Meeting physicians' responsibilities in providing end-of-life care

Despite many clinical examples of exemplary end-of-life care, a number of studies highlight significant shortcomings in the quality of end-of-life care that the majority of patients receive. In part, this stems from inconsistencies in training and supporting clinicians in delivering end-of-life care. This review describes the responsibilities of pulmonary and critical care physicians in providing end-of-life care to patients and their families. While many responsibilities are common to all physicians who care for patients with life-limiting illness, some issues are particularly relevant to pulmonary and critical care physicians. These issues include prognostication and decision making about goals of care, challenges and approaches to communicating with patients and their family, the role of interdisciplinary collaboration, principles and practice of withholding and withdrawing life-sustaining measures, and cultural competency in end-of-life care.

Burnout syndrome among critical care healthcare workers

PURPOSE OF REVIEW

Burnout syndrome is a psychological state resulting from prolonged exposure to job stressors. Because ICUs are characterized by a high level of work-related stress, a factor known to increase the risk of burnout syndrome, we sought to review the available literature on burnout syndrome in ICU healthcare workers.

RECENT FINDINGS

Based on most recent studies, severe burnout syndrome (as measured using the Maslach Burnout Inventory) is present in about 50% of critical care physicians and in one third of critical care nurses. Strikingly, determinants of burnout syndrome are different in the two groups of caregivers. Namely, intensivists who have severe burnout syndrome are those with a high number of working hours (number of night shifts and time from last vacation) but determinants of severe burnout syndrome in ICU-nurses are related to ICU organization and end-of-life-related characteristics. ICU conflicts, however, were independent predictors of severe burnout syndrome in both groups.

SUMMARY

Recent studies reported high levels of severe burnout syndrome in ICU healthcare workers and identified potential targets for preventive strategies such as ICU working groups, communication strategies during end-of-life care and prevention and management of ICU conflicts.

Bench-to-bedside review: leadership and conflict management in the intensive care unit

In the management of critical care units, leadership and conflict management are vital areas for the successful performance of the unit. In this article a practical approach to define competencies for leadership and principles and practices of conflict management are offered. This article is, by lack of relevant intensive care unit (ICU) literature, not evidence based, but it is the result of personal experience and a study of literature on leadership as well on conflicts and negotiations in non-medical areas. From this, information was selected that was recognisable to the authors and, thus, also seems to be useful knowledge for medical doctors in the ICU environment.