Critical Care Commentary: Is it time to deconstruct the idea of intensive care unit burnout?

The concept of clinician burnout in the ICU is not new. Loosely defined as the physical, psychological, and emotional exhaustion of health-care providers working in high stress environments, this entity has been well documented among ICU physicians, nurses, and trainees for decades. The overall magnitude of this problem is very real and has been reported to be as high as 60% depending on the criteria used. Burnout risk factors vary by study and clinical duties but generally include female gender, reduced job satisfaction, fewer years of clinical experience, interpersonal conflicts, and ethical decisions regarding withdrawal of care. Burnout leads to a spectrum of counter-productive defense mechanisms and mood disorders ranging from depression, hopelessness, depersonalization, and rationalization to suspiciousness, aggression, and overt anxiety. Not surprisingly, the end result for many individuals suffering from burnout is instability of personal relationships, often extending beyond the workplace.

But what are the adverse effects of this environment on another vulnerable group of individuals who similarly struggle under the stresses inherent to the ICU – namely, our critically ill patients? Might they not suffer from a distinct but similar ICU ‘burnout’ phenomenon? After all, patients with serious illnesses and prolonged ICU stays certainly experience physical, psychological, and emotional exhaustion. They often struggle with dissatisfaction related to their quality of life, interpersonal conflicts, and difficult decision making regarding their own disability and/or mortality. And although the duration of these stressors are usually brief when compared with those imposed on ICU providers, the intensity of these pressures are likely magnified exponentially for critically ill patients. Accordingly, the resulting product of ICU stress duration and intensity may not be very different for clinicians and patients.

As ICU clinicians, we are generally facile in identifying the sequelae of depression, hopelessness, rationalization, aggression, and/or anxiety in our ICU patients. But we are quick to minimize the consequences, assuming that these changes are reactive to the acute illness and are destined to resolve quickly as the patient recovers from their physical misadventure. The increasingly evident truth, however, is that these patients’ encounters with the ICU have the alarming potential for prolonged consequences that are eerily similar to the syndrome of burnout that the ICU inflicts on many health-care providers.

Although only in the infancy of its elucidation, the effects of ICU care on survivors of critical illness are beginning to come into sharper focus. Our early evaluations suggested that the incidence of posttraumatic stress disorder (PTSD) shortly after critical illness approached 50% (Jones et al. Crit Care Med. 2003;31[10]:2456). Subsequent investigators estimate that while many ICU patients have isolated PTSD symptoms, many of which overlap with the burnout syndrome we have already discussed, overt PTSD that persists with a long-term horizon occurs in between 10% and 20% of ICU survivors (Davydov et al. Gen Hosp Psychiatry. 2013;35[3]:226). Risk factors for PTSD in the ICU cohort appear to include pre-existing psychiatric disease, younger age, female gender, ICU delirium, vivid ICU memories, and delusions or hallucinations. There is a disquieting degree of overlap between this list of PTSD risk factors and the variables previously reported as predisposing to ICU clinician burnout.

A recent study using meta-analysis techniques has further refined our appreciation of the prevalence of “clinically important posttraumatic stress disorder symptoms” (Parker et al. Crit Care Med. 2015;43[5]:1121). This systematic literature review and rigorous analysis suggest that between 17% and 34% of patients continue to experience PTSD symptoms during the 7 to12 month post-ICU period (depending on where we set the bar for clinically important symptoms). This syndrome, while not meeting strict PTSD-defining criteria, has been associated with a reduced quality of life, and one could easily consider this to be an equivalent of ICU burnout.

Equally distressing, but less well elucidated, is the effect the ICU experience can have on the individuals who surround ICU survivors during their more prolonged recovery from intensive care. A timely study of informal caregivers for survivors of critical illness – typically their family members – found that up to 29% of the patients’ caregivers suffer from depressive symptoms 1 year after critical illness (Haines et al. Crit Care Med. 2015;43[5]:1112). This estimate is surprisingly similar to the rates of PTSD symptoms in the ICU survivors and is in line with ICU provider burnout rates. So, perhaps there is yet another analogous form of ICU burnout – one that afflicts family members? In retrospect, this should not be surprising given that these individuals also suffer distinct forms of physical, psychological, and emotional exhaustion.

Given these observations, it is apparent that the ICU is a double-edged sword, one that provides remarkable degrees of physical healing for many people, yet causes profound emotional harm in others. However, these entities have remained compartmentalized until this point in time: burnout occurs only in the health-care providers, PTSD is the domain of the patients, and depression is seen among the caregivers. But perhaps these apparently separate entities are actually interconnected and represent points on the bigger spectrum of critical illness-associated burnout (for lack of a better term). Although the data regarding risk factors for burnout/PTSD/depression are not robust, there is significant overlap of these items (gender, age/experience, satisfaction domains, degrees of conflict, emotional decision making) among providers, patients, and caregivers. Is this yet another signal that these entities may be more similar than they are different? At the end of the day, perhaps we have even more in common with our ICU patients and their caregivers than we have previously recognized.

A critically important reason to better understand the interconnectedness of these entities (or lack thereof) lies with our ability to eventually provide meaningful prevention strategies. Effective interventions for reducing health-care provider burnout have included resilience training and rotating responsibilities to mandate tours of duty outside the ICU are interspersed with brief (less than 2 weeks) ICU stretches. In the ICU patient population, a daily care diary has been associated with a significant reduction in PTSD symptoms. The data are scant regarding prevention of caregiver depression but one small study of journaling and reflection suggests benefit. To date, no strategy with efficacy in one cohort has been extrapolated to another.

As such, we have a significant task ahead of us. We need to better understand the ICU-related burnout/PTSD/depression syndrome and to delineate its common ground for clinicians, patients, and families. With ongoing evaluation and reflection, we will ultimately evolve ICU care to the point where interrelated strategies are employed that allow us to effectively heal patients physically while avoiding this critical care burnout syndrome that insidiously affects us all.

Dr. Morrow is Section Editor of Critical Care Commentary.

The concept of clinician burnout in the ICU is not new. Loosely defined as the physical, psychological, and emotional exhaustion of health-care providers working in high stress environments, this entity has been well documented among ICU physicians, nurses, and trainees for decades. The overall magnitude of this problem is very real and has been reported to be as high as 60% depending on the criteria used. Burnout risk factors vary by study and clinical duties but generally include female gender, reduced job satisfaction, fewer years of clinical experience, interpersonal conflicts, and ethical decisions regarding withdrawal of care. Burnout leads to a spectrum of counter-productive defense mechanisms and mood disorders ranging from depression, hopelessness, depersonalization, and rationalization to suspiciousness, aggression, and overt anxiety. Not surprisingly, the end result for many individuals suffering from burnout is instability of personal relationships, often extending beyond the workplace.

But what are the adverse effects of this environment on another vulnerable group of individuals who similarly struggle under the stresses inherent to the ICU – namely, our critically ill patients? Might they not suffer from a distinct but similar ICU ‘burnout’ phenomenon? After all, patients with serious illnesses and prolonged ICU stays certainly experience physical, psychological, and emotional exhaustion. They often struggle with dissatisfaction related to their quality of life, interpersonal conflicts, and difficult decision making regarding their own disability and/or mortality. And although the duration of these stressors are usually brief when compared with those imposed on ICU providers, the intensity of these pressures are likely magnified exponentially for critically ill patients. Accordingly, the resulting product of ICU stress duration and intensity may not be very different for clinicians and patients.

As ICU clinicians, we are generally facile in identifying the sequelae of depression, hopelessness, rationalization, aggression, and/or anxiety in our ICU patients. But we are quick to minimize the consequences, assuming that these changes are reactive to the acute illness and are destined to resolve quickly as the patient recovers from their physical misadventure. The increasingly evident truth, however, is that these patients’ encounters with the ICU have the alarming potential for prolonged consequences that are eerily similar to the syndrome of burnout that the ICU inflicts on many health-care providers.

Although only in the infancy of its elucidation, the effects of ICU care on survivors of critical illness are beginning to come into sharper focus. Our early evaluations suggested that the incidence of posttraumatic stress disorder (PTSD) shortly after critical illness approached 50% (Jones et al. Crit Care Med. 2003;31[10]:2456). Subsequent investigators estimate that while many ICU patients have isolated PTSD symptoms, many of which overlap with the burnout syndrome we have already discussed, overt PTSD that persists with a long-term horizon occurs in between 10% and 20% of ICU survivors (Davydov et al. Gen Hosp Psychiatry. 2013;35[3]:226). Risk factors for PTSD in the ICU cohort appear to include pre-existing psychiatric disease, younger age, female gender, ICU delirium, vivid ICU memories, and delusions or hallucinations. There is a disquieting degree of overlap between this list of PTSD risk factors and the variables previously reported as predisposing to ICU clinician burnout.

A recent study using meta-analysis techniques has further refined our appreciation of the prevalence of “clinically important posttraumatic stress disorder symptoms” (Parker et al. Crit Care Med. 2015;43[5]:1121). This systematic literature review and rigorous analysis suggest that between 17% and 34% of patients continue to experience PTSD symptoms during the 7 to12 month post-ICU period (depending on where we set the bar for clinically important symptoms). This syndrome, while not meeting strict PTSD-defining criteria, has been associated with a reduced quality of life, and one could easily consider this to be an equivalent of ICU burnout.

Equally distressing, but less well elucidated, is the effect the ICU experience can have on the individuals who surround ICU survivors during their more prolonged recovery from intensive care. A timely study of informal caregivers for survivors of critical illness – typically their family members – found that up to 29% of the patients’ caregivers suffer from depressive symptoms 1 year after critical illness (Haines et al. Crit Care Med. 2015;43[5]:1112). This estimate is surprisingly similar to the rates of PTSD symptoms in the ICU survivors and is in line with ICU provider burnout rates. So, perhaps there is yet another analogous form of ICU burnout – one that afflicts family members? In retrospect, this should not be surprising given that these individuals also suffer distinct forms of physical, psychological, and emotional exhaustion.

Given these observations, it is apparent that the ICU is a double-edged sword, one that provides remarkable degrees of physical healing for many people, yet causes profound emotional harm in others. However, these entities have remained compartmentalized until this point in time: burnout occurs only in the health-care providers, PTSD is the domain of the patients, and depression is seen among the caregivers. But perhaps these apparently separate entities are actually interconnected and represent points on the bigger spectrum of critical illness-associated burnout (for lack of a better term). Although the data regarding risk factors for burnout/PTSD/depression are not robust, there is significant overlap of these items (gender, age/experience, satisfaction domains, degrees of conflict, emotional decision making) among providers, patients, and caregivers. Is this yet another signal that these entities may be more similar than they are different? At the end of the day, perhaps we have even more in common with our ICU patients and their caregivers than we have previously recognized.

A critically important reason to better understand the interconnectedness of these entities (or lack thereof) lies with our ability to eventually provide meaningful prevention strategies. Effective interventions for reducing health-care provider burnout have included resilience training and rotating responsibilities to mandate tours of duty outside the ICU are interspersed with brief (less than 2 weeks) ICU stretches. In the ICU patient population, a daily care diary has been associated with a significant reduction in PTSD symptoms. The data are scant regarding prevention of caregiver depression but one small study of journaling and reflection suggests benefit. To date, no strategy with efficacy in one cohort has been extrapolated to another.

As such, we have a significant task ahead of us. We need to better understand the ICU-related burnout/PTSD/depression syndrome and to delineate its common ground for clinicians, patients, and families. With ongoing evaluation and reflection, we will ultimately evolve ICU care to the point where interrelated strategies are employed that allow us to effectively heal patients physically while avoiding this critical care burnout syndrome that insidiously affects us all.

Dr. Morrow is Section Editor of Critical Care Commentary.

The concept of clinician burnout in the ICU is not new. Loosely defined as the physical, psychological, and emotional exhaustion of health-care providers working in high stress environments, this entity has been well documented among ICU physicians, nurses, and trainees for decades. The overall magnitude of this problem is very real and has been reported to be as high as 60% depending on the criteria used. Burnout risk factors vary by study and clinical duties but generally include female gender, reduced job satisfaction, fewer years of clinical experience, interpersonal conflicts, and ethical decisions regarding withdrawal of care. Burnout leads to a spectrum of counter-productive defense mechanisms and mood disorders ranging from depression, hopelessness, depersonalization, and rationalization to suspiciousness, aggression, and overt anxiety. Not surprisingly, the end result for many individuals suffering from burnout is instability of personal relationships, often extending beyond the workplace.

But what are the adverse effects of this environment on another vulnerable group of individuals who similarly struggle under the stresses inherent to the ICU – namely, our critically ill patients? Might they not suffer from a distinct but similar ICU ‘burnout’ phenomenon? After all, patients with serious illnesses and prolonged ICU stays certainly experience physical, psychological, and emotional exhaustion. They often struggle with dissatisfaction related to their quality of life, interpersonal conflicts, and difficult decision making regarding their own disability and/or mortality. And although the duration of these stressors are usually brief when compared with those imposed on ICU providers, the intensity of these pressures are likely magnified exponentially for critically ill patients. Accordingly, the resulting product of ICU stress duration and intensity may not be very different for clinicians and patients.

As ICU clinicians, we are generally facile in identifying the sequelae of depression, hopelessness, rationalization, aggression, and/or anxiety in our ICU patients. But we are quick to minimize the consequences, assuming that these changes are reactive to the acute illness and are destined to resolve quickly as the patient recovers from their physical misadventure. The increasingly evident truth, however, is that these patients’ encounters with the ICU have the alarming potential for prolonged consequences that are eerily similar to the syndrome of burnout that the ICU inflicts on many health-care providers.

Although only in the infancy of its elucidation, the effects of ICU care on survivors of critical illness are beginning to come into sharper focus. Our early evaluations suggested that the incidence of posttraumatic stress disorder (PTSD) shortly after critical illness approached 50% (Jones et al. Crit Care Med. 2003;31[10]:2456). Subsequent investigators estimate that while many ICU patients have isolated PTSD symptoms, many of which overlap with the burnout syndrome we have already discussed, overt PTSD that persists with a long-term horizon occurs in between 10% and 20% of ICU survivors (Davydov et al. Gen Hosp Psychiatry. 2013;35[3]:226). Risk factors for PTSD in the ICU cohort appear to include pre-existing psychiatric disease, younger age, female gender, ICU delirium, vivid ICU memories, and delusions or hallucinations. There is a disquieting degree of overlap between this list of PTSD risk factors and the variables previously reported as predisposing to ICU clinician burnout.

A recent study using meta-analysis techniques has further refined our appreciation of the prevalence of “clinically important posttraumatic stress disorder symptoms” (Parker et al. Crit Care Med. 2015;43[5]:1121). This systematic literature review and rigorous analysis suggest that between 17% and 34% of patients continue to experience PTSD symptoms during the 7 to12 month post-ICU period (depending on where we set the bar for clinically important symptoms). This syndrome, while not meeting strict PTSD-defining criteria, has been associated with a reduced quality of life, and one could easily consider this to be an equivalent of ICU burnout.

Equally distressing, but less well elucidated, is the effect the ICU experience can have on the individuals who surround ICU survivors during their more prolonged recovery from intensive care. A timely study of informal caregivers for survivors of critical illness – typically their family members – found that up to 29% of the patients’ caregivers suffer from depressive symptoms 1 year after critical illness (Haines et al. Crit Care Med. 2015;43[5]:1112). This estimate is surprisingly similar to the rates of PTSD symptoms in the ICU survivors and is in line with ICU provider burnout rates. So, perhaps there is yet another analogous form of ICU burnout – one that afflicts family members? In retrospect, this should not be surprising given that these individuals also suffer distinct forms of physical, psychological, and emotional exhaustion.

Given these observations, it is apparent that the ICU is a double-edged sword, one that provides remarkable degrees of physical healing for many people, yet causes profound emotional harm in others. However, these entities have remained compartmentalized until this point in time: burnout occurs only in the health-care providers, PTSD is the domain of the patients, and depression is seen among the caregivers. But perhaps these apparently separate entities are actually interconnected and represent points on the bigger spectrum of critical illness-associated burnout (for lack of a better term). Although the data regarding risk factors for burnout/PTSD/depression are not robust, there is significant overlap of these items (gender, age/experience, satisfaction domains, degrees of conflict, emotional decision making) among providers, patients, and caregivers. Is this yet another signal that these entities may be more similar than they are different? At the end of the day, perhaps we have even more in common with our ICU patients and their caregivers than we have previously recognized.

A critically important reason to better understand the interconnectedness of these entities (or lack thereof) lies with our ability to eventually provide meaningful prevention strategies. Effective interventions for reducing health-care provider burnout have included resilience training and rotating responsibilities to mandate tours of duty outside the ICU are interspersed with brief (less than 2 weeks) ICU stretches. In the ICU patient population, a daily care diary has been associated with a significant reduction in PTSD symptoms. The data are scant regarding prevention of caregiver depression but one small study of journaling and reflection suggests benefit. To date, no strategy with efficacy in one cohort has been extrapolated to another.

As such, we have a significant task ahead of us. We need to better understand the ICU-related burnout/PTSD/depression syndrome and to delineate its common ground for clinicians, patients, and families. With ongoing evaluation and reflection, we will ultimately evolve ICU care to the point where interrelated strategies are employed that allow us to effectively heal patients physically while avoiding this critical care burnout syndrome that insidiously affects us all.

Dr. Morrow is Section Editor of Critical Care Commentary.