An Official Critical Care Societies Collaborative Statement—Burnout Syndrome in Critical Care Health-care Professionals
2016; Elsevier BV; Volume: 150; Issue: 1 Linguagem: Inglês
10.1016/j.chest.2016.02.649
ISSN1931-3543
AutoresMarc Moss, Vicki S. Good, David Gozal, Ruth Kleinpell, Curtis N. Sessler,
Tópico(s)Family and Patient Care in Intensive Care Units
ResumoBurnout syndrome (BOS) occurs in all types of health-care professionals and is especially common in individuals who care for critically ill patients. The development of BOS is related to an imbalance of personal characteristics of the employee and work-related issues or other organizational factors. BOS is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care. BOS also directly affects the mental health and physical well-being of the many critical care physicians, nurses, and other health-care professionals who practice worldwide. Until recently, BOS and other psychological disorders in critical care health-care professionals remained relatively unrecognized. To raise awareness of BOS, the Critical Care Societies Collaborative (CCSC) developed this call to action. The present article reviews the diagnostic criteria, prevalence, causative factors, and consequences of BOS. It also discusses potential interventions that may be used to prevent and treat BOS. Finally, we urge multiple stakeholders to help mitigate the development of BOS in critical care health-care professionals and diminish the harmful consequences of BOS, both for critical care health-care professionals and for patients. Burnout syndrome (BOS) occurs in all types of health-care professionals and is especially common in individuals who care for critically ill patients. The development of BOS is related to an imbalance of personal characteristics of the employee and work-related issues or other organizational factors. BOS is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care. BOS also directly affects the mental health and physical well-being of the many critical care physicians, nurses, and other health-care professionals who practice worldwide. Until recently, BOS and other psychological disorders in critical care health-care professionals remained relatively unrecognized. To raise awareness of BOS, the Critical Care Societies Collaborative (CCSC) developed this call to action. The present article reviews the diagnostic criteria, prevalence, causative factors, and consequences of BOS. It also discusses potential interventions that may be used to prevent and treat BOS. Finally, we urge multiple stakeholders to help mitigate the development of BOS in critical care health-care professionals and diminish the harmful consequences of BOS, both for critical care health-care professionals and for patients. FOR EDITORIAL COMMENT SEE PAGE 1Psychological stress develops when an individual’s external demands exceed their adaptive abilities. Although stress may help an individual become more focused, chronic and excessive stress has deleterious effects such as feeling pressured and being overwhelmed. Extreme stress can result in insomnia, fatigue, irritability, anxiety, and depression. For many adults, the demands from their work environment are a major contributor to feeling stressed. Due to increasing expectations, longer hours, and a relative lack of community support in the workplace, the amount of work-related stress has increased over the last few decades. As a result, burnout syndrome (BOS) has become a common worldwide phenomenon, especially among members of high-stress professions: firefighters, police officers, teachers, and all types of health-care professionals. Compared with all high school graduates, physicians were 36% more likely to develop BOS.1Shanafelt T.D. Boone S. Tan L. et al.Burnout and satisfaction with work-life balance among US physicians relative to the general US population.Arch Intern Med. 2012; 172: 1377-1385Crossref PubMed Scopus (1895) Google Scholar Among physicians, those at the front line of care (family medicine, emergency medicine, and general internal medicine) report the highest rates of BOS (ie, > 40%). FOR EDITORIAL COMMENT SEE PAGE 1 Working in an ICU can be especially stressful because of the high patient morbidity and mortality, challenging daily work routines, and regular encounters with traumatic and ethical issues.2Donchin Y. Seagull F.J. The hostile environment of the intensive care unit.Curr Opin Crit Care. 2002; 8: 316-320Crossref PubMed Scopus (202) Google Scholar, 3Mealer M.L. Shelton A. Berg B. Rothbaum B. Moss M. Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses.Am J Respir Crit Care Med. 2007; 175: 693-697Crossref PubMed Scopus (231) Google Scholar This level of nearly continuous and excessive stress can rapidly accelerate when caregivers perceive that there is insufficient time or limited resources to properly care for patients. Until recently, the critical care community was relatively unaware of the harmful effects of working in a stressful ICU environment, including the development of BOS and other psychological disorders.3Mealer M.L. Shelton A. Berg B. Rothbaum B. Moss M. Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses.Am J Respir Crit Care Med. 2007; 175: 693-697Crossref PubMed Scopus (231) Google Scholar, 4Azoulay E. Herridge M. Understanding ICU staff burnout: the show must go on.Am J Respir Crit Care Med. 2011; 184: 1099-1100Crossref PubMed Scopus (29) Google Scholar, 5Chlan L.L. Burnout syndrome among critical care professionals: a cause for alarm.Critical Care Alert. 2013; 21: 65-68Google Scholar, 6Embriaco N. Papazian L. Kentish-Barnes N. Pochard F. Azoulay E. Burnout syndrome among critical care healthcare workers.Curr Opin Crit Care. 2007; 13: 482-488Crossref PubMed Scopus (358) Google Scholar, 7Embriaco N. Azoulay E. Barrau K. et al.High level of burnout in intensivists: prevalence and associated factors.Am J Respir Crit Care Med. 2007; 175: 686-692Crossref PubMed Scopus (496) Google Scholar, 8Merlani P. Verdon M. Businger A. et al.Burnout in ICU caregivers: a multicenter study of factors associated to centers.Am J Respir Crit Care Med. 2011; 184: 1140-1146Crossref PubMed Scopus (113) Google Scholar, 9Piers R.D. Azoulay E. Ricou B. et al.Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians.JAMA. 2011; 306: 2694-2703Crossref PubMed Scopus (241) Google Scholar, 10Poncet M.C. Toullic P. Papazian L. et al.Burnout syndrome in critical care nursing staff.Am J Respir Crit Care Med. 2007; 175: 698-704Crossref PubMed Scopus (491) Google Scholar Unfortunately, critical care health-care professionals have one of the highest rates of BOS (ie, > 50%),11Peckham C. Medscape physician lifestyle report 2015. http://www.medscape.com/features/slideshow/lifestyle/2015/public/overview#1. Accessed January 26, 2015.Google Scholar and development of this disorder may adversely affect the ability to care for patients properly. The Critical Care Societies Collaborative (CCSC) comprises four major US professional and scientific societies: the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine. The CCSC convened a working group to acknowledge the importance of BOS and other psychological disorders in critical care health-care professionals and to publish a document in the society’s four major journals that would focus attention on this issue. The primary objectives of the present commentary were to: (1) summarize the available literature regarding the diagnostic criteria, prevalence, causative factors, and consequences of BOS and related conditions, (2) raise awareness of BOS within the critical care community, and (3) inform multiple stakeholders of their potential roles in reducing BOS and its deleterious consequences in health-care professionals and their critically ill patients. We searched the Cochrane Library and Medline by using PubMed for published research relevant to BOS. A variety of search terms were entered, including (but not limited to) the following: “burnout syndrome,” “critical care,” “nursing,” “posttraumatic stress disorder,” “moral distress,” “resiliency,” and “mindfulness.” Search terms were grouped together and individually cross-matched. Pertinent review articles, editorials, books, and references from identified articles were also reviewed. We preferentially selected publications from the past 10 years but also included commonly referenced or highly regarded older publications. First described in the 1970s, BOS is a work-related constellation of symptoms and signs that usually occurs in individuals with no history of psychological or psychiatric disorders.12Maslach C. Leiter M.P. The Truth About Burnout. Josset-Bass Publishers, San Francisco, CA1997Google Scholar BOS is triggered by a discrepancy between the expectations and ideals of the employee and the actual requirements of his or her position. Symptoms of BOS typically develop gradually and are usually absent when entering a new type of employment. In the initial stages of BOS, individuals feel emotional stress and increasing job-related disillusionment.13Edelwich J. Brodsky A. Burn-out: Stages of Disillusionment in the Helping Professions. Human Services Press, New York, NY1980Google Scholar They subsequently lose the ability to adapt to the work environment and display negative attitudes toward their job, their coworkers, and their patients. Eventually, the three classic symptoms of BOS develop: exhaustion, depersonalization, and reduced personal accomplishment.14Maslach C. Jackson S.E. MBI: Maslach Burnout Inventory; Manual Research Edition. Consulting Psychologists Press, Palo Alto, CA1986Google Scholar Exhaustion is generalized fatigue that can be related to devoting excessive time and effort to a task or project that is not perceived to be beneficial. For example, a feeling of exhaustion, particularly emotional exhaustion, may be caused by continuing to care for a patient who has a very poor chance of recovery. Depersonalization is a distant or indifferent attitude toward work. It manifests as negative, callous, and cynical behaviors or interaction with colleagues or patients in an impersonal manner. Depersonalization may be expressed as unprofessional comments directed toward coworkers, blaming patients for their medical problems, or the inability to express empathy or grief when a patient dies. Reduced personal accomplishment is the tendency to negatively evaluate the worth of one’s work, feeling insufficient regarding the ability to perform one’s job, and a generalized poor professional self-esteem. Individuals with BOS may also develop nonspecific symptoms such as feeling frustrated, angry, fearful, or anxious (Table 1). They may also express an inability to feel happiness, joy, pleasure, or contentment. BOS can be associated with physical symptoms, including insomnia, muscle tension, headaches, and gastrointestinal problems. BOS is most commonly diagnosed by using the Maslach Burnout Inventory (MBI).14Maslach C. Jackson S.E. MBI: Maslach Burnout Inventory; Manual Research Edition. Consulting Psychologists Press, Palo Alto, CA1986Google Scholar The MBI is a 22-item, self-report questionnaire that asks respondents to indicate on a seven-point Likert scale the frequency with which they experience certain feelings related to their job. The MBI is scored according to the presence and severity of emotional exhaustion, depersonalization, and reduced sense of personal accomplishment. Individuals are diagnosed with BOS if they exceed a cutoff value on the MBI. However, accurate cutoff values for critical care health-care providers have not been determined. As a result, the diagnostic criteria for BOS vary across studies, making comparisons difficult from one study to another.Table 1Symptoms Associated With Burnout SyndromePsychological SymptomsPhysical SymptomsFrustrationExhaustion/FatigueAngerInsomniaFearMuscle tensionAnxiousHeadacheInability to feel happyGI problemsBeing unprofessionalFeeling overwhelmedDisillusionmentHopelessnessLack of empathyFeeling insufficient at work Open table in a new tab Other conditions may overlap with BOS, including moral distress, perceived delivery of inappropriate care, and compassion fatigue (also called secondary traumatic stress).9Piers R.D. Azoulay E. Ricou B. et al.Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians.JAMA. 2011; 306: 2694-2703Crossref PubMed Scopus (241) Google Scholar, 15Corley M.C. Minick P. Moral distress or moral comfort.Bioethics Forum. 2002; 18: 7-14PubMed Google Scholar, 16Jameton A. Jackson E.M. Nuclear war and nursing ethics. What is the nurse's responsibility?.Mobius. 1984; 4: 75-88PubMed Google Scholar, 17Wiegand D.L. Funk M. Consequences of clinical situations that cause critical care nurses to experience moral distress.Nurs Ethics. 2012; 19: 479-487Crossref PubMed Scopus (132) Google Scholar, 18Hinderer K.A. VonRueden K.T. Friedmann E. et al.Burnout, compassion fatigue, compassion satisfaction, and secondary traumatic stress in trauma nurses.J Trauma Nurs. 2014; 21: 160-169Crossref PubMed Scopus (155) Google Scholar, 19Dominguez-Gomez E. Rutledge D.N. Prevalence of secondary traumatic stress among emergency nurses.J Emerg Nurs. 2009; 35: 199-204Abstract Full Text Full Text PDF PubMed Scopus (186) Google Scholar Moral distress occurs when an individual knows the ethical and appropriate action to take but feels constrained from enacting the specific action. Moral distress may be related to internal constraints such as self-doubt, anxiety about creating a conflict, and a lack of confidence. Moral distress may also be related to external constraints such as imbalances in perceived power (eg, between a nurse and a physician), inadequate communication strategies, and pressure to reduce costs or avoid legal ramifications. Clinicians consider care to be inappropriate when it is not aligned with their personal beliefs or professional knowledge. Examples of perceived inappropriate care include: (1) differences in the amount of care given and the expected prognosis (either too much or too little care), (2) caring for patients who are persistently noncompliant, (3) holding the belief that other patients would benefit more from ICU care, (4) delivering inaccurate information to a patient or family, (5) not respecting the expressed wishes of a patient, and (6) delivering medical or nursing care believed to be of inadequate quality.9Piers R.D. Azoulay E. Ricou B. et al.Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians.JAMA. 2011; 306: 2694-2703Crossref PubMed Scopus (241) Google Scholar Compassion fatigue is characterized by a gradual reduction in compassion over time that results from a cumulative and persistent desire to help suffering patients; it is sometimes referred to as “the cost of caring.” Moral distress, delivery of inappropriate care, and compassion fatigue occur in critical care health-care professionals. For example, the perception of inappropriate care occurs in 25% of critical care nurses and 32% of critical care physicians. Based upon multiple studies, approximately 25% to 33% of critical care nurses manifest symptoms of severe BOS, and up to 86% have at least one of the three classic symptoms.6Embriaco N. Papazian L. Kentish-Barnes N. Pochard F. Azoulay E. Burnout syndrome among critical care healthcare workers.Curr Opin Crit Care. 2007; 13: 482-488Crossref PubMed Scopus (358) Google Scholar, 10Poncet M.C. Toullic P. Papazian L. et al.Burnout syndrome in critical care nursing staff.Am J Respir Crit Care Med. 2007; 175: 698-704Crossref PubMed Scopus (491) Google Scholar, 20Mealer M. Burnham E.L. Goode C.J. Rothbaum B. Moss M. The prevalence and impact of post traumatic stress disorder and burnout syndrome in nurses.Depress Anxiety. 2009; 26: 1118-1126Crossref PubMed Scopus (253) Google Scholar, 21Mealer M. Jones J. Newman J. McFann K.K. Rothbaum B. Moss M. The presence of resilience is associated with a healthier psychological profile in intensive care unit (ICU) nurses: results of a national survey.Int J Nurs Stud. 2012; 49: 292-299Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar, 22Patrick K. Lavery J.F. Burnout in nursing.Aust J Adv Nurs. 2007; 24: 43-48PubMed Google Scholar, 23Regan A. Howard R.A. Oyebode J.R. Emotional exhaustion and defense mechanisms in intensive therapy unit nurses.J Nerv Ment Dis. 2009; 197: 330-336Crossref PubMed Scopus (22) Google Scholar Compared with other types of nurses, critical care nurses more commonly experience BOS.5Chlan L.L. Burnout syndrome among critical care professionals: a cause for alarm.Critical Care Alert. 2013; 21: 65-68Google Scholar, 24Epp K. Burnout in critical care nurses: a literature review.Dynamics. 2012; 23: 25-31PubMed Google Scholar In critical care nurses, the most common symptom of BOS is emotional exhaustion (73%), followed by a lack of personal accomplishment (60%) and depersonalization (48%).20Mealer M. Burnham E.L. Goode C.J. Rothbaum B. Moss M. The prevalence and impact of post traumatic stress disorder and burnout syndrome in nurses.Depress Anxiety. 2009; 26: 1118-1126Crossref PubMed Scopus (253) Google Scholar The prevalence of BOS in critical care nurses also varies across certain ICUs; nurses who reported the highest prevalence of BOS among their colleagues were also more likely to have BOS themselves. Therefore, units with a negative working culture might harbor a “contagion effect” among its employees.25Bakker A.B. Le Blanc P.M. Schaufeli W.B. Burnout contagion among intensive care nurses.J Adv Nurs. 2005; 51: 276-287Crossref PubMed Scopus (284) Google Scholar The relative shortage of critical care physicians and the demands for overnight ICU coverage have increased the awareness and recognition of BOS among physicians.5Chlan L.L. Burnout syndrome among critical care professionals: a cause for alarm.Critical Care Alert. 2013; 21: 65-68Google Scholar BOS is common in critical care physicians as well.7Embriaco N. Azoulay E. Barrau K. et al.High level of burnout in intensivists: prevalence and associated factors.Am J Respir Crit Care Med. 2007; 175: 686-692Crossref PubMed Scopus (496) Google Scholar, 26Dyrbye L.N. Thomas M.R. Massie F.S. et al.Burnout and suicidal ideation among US medical students.Ann Intern Med. 2008; 149: 334-341Crossref PubMed Scopus (857) Google Scholar, 27Dyrbye L.N. Varkey P. Boone S.L. Satele D.V. Sloan J.A. Shanafelt T.D. Physician satisfaction and burnout at different career stages.Mayo Clin Proc. 2013; 88: 1358-1367Abstract Full Text Full Text PDF PubMed Scopus (328) Google Scholar, 28Garcia T.T. Garcia P.C. Molon M.E. et al.Prevalence of burnout in pediatric intensivists: an observational comparison with general pediatricians.Pediatr Crit Care Med. 2014; 15: e347-e353Crossref PubMed Scopus (58) Google Scholar, 29Shanafelt T. Dyrbye L. Oncologist burnout: causes, consequences, and responses.J Clin Oncol. 2012; 30: 1235-1241Crossref PubMed Scopus (184) Google Scholar, 30Shanafelt T.D. Oreskovich M.R. Dyrbye L.N. et al.Avoiding burnout: the personal health habits and wellness practices of US surgeons.Ann Surg. 2012; 255: 625-633Crossref PubMed Scopus (191) Google Scholar Up to 45% of critical care physicians reported symptoms of severe BOS.7Embriaco N. Azoulay E. Barrau K. et al.High level of burnout in intensivists: prevalence and associated factors.Am J Respir Crit Care Med. 2007; 175: 686-692Crossref PubMed Scopus (496) Google Scholar, 28Garcia T.T. Garcia P.C. Molon M.E. et al.Prevalence of burnout in pediatric intensivists: an observational comparison with general pediatricians.Pediatr Crit Care Med. 2014; 15: e347-e353Crossref PubMed Scopus (58) Google Scholar In pediatric critical care physicians, the prevalence of BOS is 71%, more than twice the rate in general pediatricians. Compared with other types of physicians, critical care physicians have the highest prevalence of BOS, followed closely by emergency medicine physicians.11Peckham C. Medscape physician lifestyle report 2015. http://www.medscape.com/features/slideshow/lifestyle/2015/public/overview#1. Accessed January 26, 2015.Google Scholar There is a paucity of data on the prevalence of BOS in other critical care health-care professionals, such as social workers, and respiratory, physical, occupational, or speech therapy health-care professionals.31Murji A. Gomez M. Knighton J. Fish J.S. Emotional implications of working in a burn unit.J Burn Care Res. 2006; 27: 8-13Crossref PubMed Scopus (18) Google Scholar In one study, nursing assistants were more likely to have BOS compared with other types of critical care health-care professionals.8Merlani P. Verdon M. Businger A. et al.Burnout in ICU caregivers: a multicenter study of factors associated to centers.Am J Respir Crit Care Med. 2011; 184: 1140-1146Crossref PubMed Scopus (113) Google Scholar The ability to determine the temporal relationship between the majority of risk factors and the development of BOS is hampered by the cross-sectional design of most previous studies. Risk factors associated with BOS can be divided into four categories: (1) personal characteristics, (2) organizational factors, (3) quality of working relationships, and (4) exposure to end-of-life issues (Fig 1).10Poncet M.C. Toullic P. Papazian L. et al.Burnout syndrome in critical care nursing staff.Am J Respir Crit Care Med. 2007; 175: 698-704Crossref PubMed Scopus (491) Google Scholar Personal characteristics associated with BOS include being self-critical, engaging in unhelpful coping strategies, sleep deprivation, and a work-life imbalance.32Shanafelt T.D. Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care.JAMA. 2009; 302: 1338-1340Crossref PubMed Scopus (231) Google Scholar Other personal risk factors associated with BOS are idealism, perfectionism, and overcommitment; these qualities often occur in the best and most productive employees. Certain personality types, such as neurotic individuals, also reportedly have higher rates of BOS; extraverted, conscientious, and agreeable individuals, conversely, are less likely to demonstrate symptoms of BOS.33Cañadas-De la Fuente G.A. Vargas C. San Luis C. García I. Cañadas G.R. De la Fuente E.I. Risk factors and prevalence of burnout syndrome in the nursing profession.Int J Nurs Stud. 2015; 52: 240-249Abstract Full Text Full Text PDF PubMed Scopus (262) Google Scholar Burnout was once thought to be a late career-phenomenon, but studies suggest that younger physicians have nearly twice the prevalence of BOS compared with older colleagues and that onset may occur as early as residency training.34Shanafelt T.D. Sloan J.A. Habermann T.M. The well-being of physicians.Am J Med. 2003; 114: 513-519Abstract Full Text Full Text PDF PubMed Scopus (499) Google Scholar Similarly, younger age is an independent risk factor for BOS among ICU nurses.10Poncet M.C. Toullic P. Papazian L. et al.Burnout syndrome in critical care nursing staff.Am J Respir Crit Care Med. 2007; 175: 698-704Crossref PubMed Scopus (491) Google Scholar However, older health-care professionals who have not developed BOS may be those who remained in the work force and are therefore overrepresented in cross-sectional studies. Having an inadequate support system outside of the work environment (eg, having no spouse, partner, or children) has also been associated with high rates of BOS.8Merlani P. Verdon M. Businger A. et al.Burnout in ICU caregivers: a multicenter study of factors associated to centers.Am J Respir Crit Care Med. 2011; 184: 1140-1146Crossref PubMed Scopus (113) Google Scholar, 20Mealer M. Burnham E.L. Goode C.J. Rothbaum B. Moss M. The prevalence and impact of post traumatic stress disorder and burnout syndrome in nurses.Depress Anxiety. 2009; 26: 1118-1126Crossref PubMed Scopus (253) Google Scholar, 35Teixeira C. Ribeiro O. Fonseca A.M. Carvalho A.S. Burnout in intensive care units—a consideration of the possible prevalence and frequency of new risk factors: a descriptive correlational multicentre study.BMC Anesthesiol. 2013; 13: 38Crossref PubMed Scopus (85) Google Scholar In general, organizational factors associated with BOS include: (1) increasing workload, (2) lack of control over the work environment, (3) insufficient rewards, and (4) a general breakdown in the work community.12Maslach C. Leiter M.P. The Truth About Burnout. Josset-Bass Publishers, San Francisco, CA1997Google Scholar Organizational factors that are associated with BOS seem to differ between critical care nurses and physicians. For critical care nurses, the inability to choose days off, rapid patient turnover, and the lack of participation in an ICU working group are all factors associated with BOS.5Chlan L.L. Burnout syndrome among critical care professionals: a cause for alarm.Critical Care Alert. 2013; 21: 65-68Google Scholar, 10Poncet M.C. Toullic P. Papazian L. et al.Burnout syndrome in critical care nursing staff.Am J Respir Crit Care Med. 2007; 175: 698-704Crossref PubMed Scopus (491) Google Scholar For critical care physicians, the amount of work (defined as number of night shifts per month and time since the last nonworking week) was associated with the presence of BOS.7Embriaco N. Azoulay E. Barrau K. et al.High level of burnout in intensivists: prevalence and associated factors.Am J Respir Crit Care Med. 2007; 175: 686-692Crossref PubMed Scopus (496) Google Scholar For example, weekend coverage schedules affect the risk of BOS. Compared with having weekend coverage by another physician, working a continuous 14-day period of direct patient care was associated with increased symptoms of BOS.36Ali N.A. Hammersley J. Hoffmann S.P. et al.Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing.Am J Respir Crit Care Med. 2011; 184: 803-808Crossref PubMed Scopus (67) Google Scholar Having to make ethical decisions was also associated with higher rates of BOS for physicians. In contrast to nurses, physicians may less frequently experience moral distress, most likely because physicians are responsible for making the patient care decisions. In both nurses and physicians, problems with the quality of working relationships were common risk factors for BOS, including conflicts and poor working relationships with colleagues.5Chlan L.L. Burnout syndrome among critical care professionals: a cause for alarm.Critical Care Alert. 2013; 21: 65-68Google Scholar, 6Embriaco N. Papazian L. Kentish-Barnes N. Pochard F. Azoulay E. Burnout syndrome among critical care healthcare workers.Curr Opin Crit Care. 2007; 13: 482-488Crossref PubMed Scopus (358) Google Scholar This issue is an important and potentially modifiable risk factor because measures to improve communication and reduce conflict among critical care health-care professionals can enhance relationships. Another significant source of stress is the strained relationships between health-care professionals and patients and their families. Finally, factors related to end-of-life issues are commonly reported risk factors in nurses, including caring for a dying patient and participating in or witnessing decisions to forego life-sustaining treatments. As a result, higher unit-specific mortality rates have been associated with increased rates of BOS in critical care health-care professionals.8Merlani P. Verdon M. Businger A. et al.Burnout in ICU caregivers: a multicenter study of factors associated to centers.Am J Respir Crit Care Med. 2011; 184: 1140-1146Crossref PubMed Scopus (113) Google Scholar Another often-minimized factor underlying the risk for BOS is the nearly inevitable consequence of extended shift work: sleep disruption. This condition may take the form of insufficient sleep quantity and/or quality, or even inadequate sleep recovery, the latter requiring periods of sleep after night shifts more extensive than would normally be the case when working normal daytime schedules.36Ali N.A. Hammersley J. Hoffmann S.P. et al.Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing.Am J Respir Crit Care Med. 2011; 184: 803-808Crossref PubMed Scopus (67) Google Scholar, 37Tucker P. Bejerot E. Kecklund G. Aronsson G. Akerstedt T. The impact of work time control on physicians' sleep and well-being.Appl Ergon. 2015; 47: 109-116Crossref PubMed Scopus (55) Google Scholar, 38Howell M.D. Intensivist time allocation: economic and ethical issues surrounding how intensivists use their time.Semin Respir Crit Care Med. 2012; 33: 401-412Crossref PubMed Scopus (11) Google Scholar, 39Eanes L. CE: the potential effects of sleep loss on a nurse's health.Am J Nurs. 2015; 115: 34-40Crossref PubMed Scopus (25) Google Scholar Other unit-based factors that are associated with increased rates of BOS include working in a university hospital setting and in a pediatric critical care unit.8Merlani P. Verdon M. Businger A. et al.Burnout in ICU caregivers: a multicenter study of factors associated to centers.Am J Respir Crit Care Med. 2011; 184: 1140-1146Crossref PubMed Scopus (113) Google Scholar BOS in critical care health-care professionals may result in posttraumatic stress disorder (PTSD), alcohol abuse, and even suicidal ideation.26Dyrbye L.N. Thomas M.R. Massie F.S. et al.Burnout and suicidal ideation among US medical students.Ann Intern Med. 2008; 149: 334-341Crossref PubMed Scopus (857) Google Scholar Although alcohol and substance abuse were not specifically studied in critical care providers, physicians have higher rates of these problems compared with the general adult US population.11Peckham C. Medscape physician lifestyle report 2015. http://www.medscape.com/features/sli
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