Examining Burnout in Interprofessional Intensive Care Unit Clinicians Using Qualitative Analysis

Abstract

Background

Health care professionals working in intensive care units report a high degree of burnout, but this topic has not been extensively studied from an interdisciplinary perspective.

Objective

To characterize experiences of burnout among members of interprofessional intensive care unit teams and identify possible contributing factors.

Methods

This qualitative study involved interviews of registered nurses, respiratory therapists, physicians, pharmacists, and a personal care assistant working in multiple intensive care units of a single academic medical center to assess work stressors.

Results

Team composition was a factor in burnout, particularly when nonphysician team members felt that their opinions were not valued despite the institution’s emphasis on a multidisciplinary team-based model of care. This was especially true when roles were not well defined at the outset of a code situation. Members of nearly all disciplines stated that there was not enough time in a day to complete all the required tasks.

Conclusions

Multiple factors contribute to work-related stress and burnout across different professions in the intensive care unit. Improved communication and increased receptivity to diverse opinions among members of the multidisciplinary team may help reduce stress.

The intensive care unit (ICU) is a high-stress environment for health care professionals, patients, and patients’ families. This high-stress environment can lead to burnout, which the World Health Organization recently redefined in the International Classification of Diseases, Eleventh Revision, as a syndrome resulting from chronic workplace stress that has not been successfully managed, characterized by feelings of exhaustion, feelings of cynicism related to one’s job, and reduced professional efficacy.¹

Nurse burnout in the ICU has been associated with high patient acuity, caring for families in crisis, inadequate staffing, high levels of responsibility, and moral distress when care is perceived as futile.^2,3 Burnout also affects nearly half of ICU intensivists, with contributing factors identified as excessive workloads, extensive documentation requirements, loss of autonomy, and the intrusion of work responsibilities into the home environment.^4,5

The consequences of burnout can be catastrophic. The rate of suicide among female physicians is up to 4-fold higher than in the general population. Health care professionals experiencing burnout are prone to making major medical errors, and high degrees of burnout have been correlated with low patient satisfaction.⁵ Burnout and associated symptoms of fatigue, exhaustion, and inattentiveness can also increase the risk of motor-vehicle accidents. Moreover, symptoms of burnout can lead to premature departure from jobs, resulting in significant financial costs for the institution related to hiring and training new workers.⁵

Optimal teamwork that integrates individual-level engagement and team-level communication can both improve patients’ outcomes and reduce rates of burnout among health care professionals.^6,7 Coping strategies may mitigate burnout among ICU staff members, but little investigation has been done on factors that contribute to stress, stress management, job satisfaction, and collegial interactions across ICU disciplines.^8,9 Therefore, we sought to use qualitative analysis to identify themes among perceived contributors to burnout in the interprofessional ICU team. We hypothesized that the factors would be relatively similar across the various disciplines.

Methods

This study involved qualitative individual interviews designed to illuminate the experiences of various members of interprofessional ICU teams at the Mayo Clinic in Minnesota. We obtained approval from the Mayo Clinic’s institutional review board (IRB#15–004257) before participant recruitment. One of the authors (J.L.R.) who has expertise in qualitative research assisted with study design and qualitative data analysis. Interviews were conducted by a study team member trained in qualitative interviewing (D.J.K.) and were completed in person or by telephone according to participant preference. Participants were selected from the medical, cardiac, and cardiothoracic ICUs and were recruited through emails and flyers. Participants received a moderate financial incentive for involvement in the study. Participation was voluntary, with no consequences of lack of participation on employment, and the study investigator team did not include any supervisors of potential participants. The semistructured interview guide included questions in multiple domains including work stress, interactions with colleagues, and stress management techniques. Interviews were audio-recorded, transcribed verbatim by a medical transcriptionist, and checked for accuracy.

Our qualitative data analysis followed procedures similar to the step-by-step general qualitative analysis approach described by Creswell.¹⁰ The process is flexible but systematic, starting from reviewing the raw data to obtain a sense of the whole and ending with interpretation. In this study, analysis began with 3 study investigators (D.J.K., R.P.B., and J.L.R.) independently reading the transcripts and making notes in the margins reflecting meaning in the text. A list of codes or topics was created on the basis of structural or expected codes (codes that reflect topics in the interview guide), as well as codes that represent emergent ideas (codes that identify new insights or conceptual issues not predetermined by the interview guide). The use of a detailed codebook ensured reliable use of the coding framework. Discrepancies in themes were resolved by discussion and consensus between authors (D.J.K. and J.L.R.). Code transcripts were entered into NVivo software (NVivo 10.1, QSR International Pty Ltd) to facilitate data queries. Codes were used to generate themes, which were analyzed across cases. Review of the coded data and team discussion of commonalities and differences across cases were used to identify themes or major findings in the qualitative data. Memos were written during coding and analysis to reflect theme development, and data interpretation involved discussion of lessons learned from the data and what findings converged or diverged from existing literature on the topic.

Results

Interviews were completed with 24 participants, with 15 conducted in person and 9 by telephone: 5 ICU physicians, 3 respiratory therapists, 3 pharmacists, 12 registered nurses, and 1 personal care assistant. From these interviews, we inductively identified 2 themes: interdisciplinary dynamics and work stressors. These themes are described below. Comments from participants that exemplify meaning, with quotations identified by the participant’s sex, staff role, and number of years of ICU experience, are provided in the Table. Interviewees from multiple disciplines commented on both the positive and negative aspects of team dynamics in the ICU as related to unit codes. The factors that contributed to work stress in the ICU included administrative burden, difficult interactions with families, moral distress, and long work hours, with limited time available to complete the many tasks required during an ICU shift.

Table.

Comments from the interdisciplinary team on team dynamics, stressors, and other experiences in the intensive care unit^a

Interdisciplinary dynamics

Team dynamics:

“A lot of times, I don’t feel like I’m heard … I don’t feel like my opinion is valued or respected…. A lot of times it comes from doctors on my floor.”—Female, registered nurse, 3 years ICU experience

“I think pharmacists are in a position where we provide advice but it’s very easy for people to just say, like, nope I don’t like your advice; I think it should be different … you have to just sit and take it…. It takes away my feeling of autonomy, I guess … it degrades my feeling of worth because no matter what I say, somebody is totally able to just be like, I don’t want to do that…. ”—Female, pharmacy, 5 years ICU experience

“You feel like you’re getting decisions handed down from above that don’t always make sense … difficult to practice when it doesn’t make sense…. Shared decision making is no longer … they talk it, but they don’t do it”—Female, registered nurse, 25 years ICU experience

“The thing that I like [about working here] is collaboration … some [of the doctors don’t] believe in that … they treat … some other health care professionals not equally”—Male, respiratory therapist, 13 years ICU experience

Team dynamics of the code environment:

“When everybody does their role … the flow seems to be good. It’s very organized chaos”—Female, registered nurse, 7.5 years ICU experience

“I feel the most stress if I’m in a code and there’s no set roles.”—Female, registered nurse, 3 years ICU experience

“The only time it’s a problem is if the room is … super chaotic and people are talking over people and nobody’s listening … you just need to crowd control and get people out of the room that don’t need to be there”—Female, registered nurse, 3 years ICU experience

“It’s like the room is always too small for the number of people who are in there”—Female, pharmacy, 11 years ICU experience

“It’s sometimes difficult to obtain … the control and get people to focus on what you need … especially if there are too many people in the room.”—Female, physician, 5 years ICU experience

Work stressors

Administrative burden:

“I don’t like my inbox”—Female, physician, 3 years ICU experience

“I don’t enjoy all of the associated paperwork … it takes away from the joy of actually treating the patient.”—Female, physician, 5 years ICU experience

“[I don’t like] the more logistical and paperwork side of things … it feels like you’re just doing menial tasks”—Male, physician, <1 year ICU experience

“The things that I don’t like are policy-related … the back-end work of order entry and things we can’t change.”—Female, pharmacy,

3.5 years ICU experience

“Although we don’t punch a clock, it’s essentially 40 hours of patient care … then anything additional that I do is just bonus … you do a lot of discretionary effort to make up 60 or 80 hours a week to get that work done.”—Female, pharmacy, 5 years ICU experience

Family interactions and moral distress:

“Some of the patient population … their manner, sometimes, isn’t always respectful … that kind of burns you out a little … ”—Female, registered nurse, <1 year ICU experience

“It can be really draining … if the family have a lot of questions or they’re not communicating with each other … or they’re mean or rude”—Female, registered nurse, <1 year ICU experience

“Sometimes it’s stressful … you might feel some moral distress … you feel like you’re prolonging death. Maybe patients that you think should be comfort care or palliative care patients … maybe this isn’t in the best interest of the patient”—Female, registered nurse, 9 years ICU experience

Time limitations:

“It seems like there’s not ever enough time to get all your stuff done”—Female, registered nurse, 2 years ICU experience

“There’s so much pressure to get work done that it’s to the point where I feel almost unsafe”—Female, pharmacy, 5 years ICU experience

Code emotions:

“If I have a patient that doesn’t survive … I have a really hard time … if it’s a really young patient … or if the patient is super, super old and we shouldn’t be coding them, I really have a ton of moral distress with that.”—Female, registered nurse, 3 years ICU experience

“If it was somebody that was a younger adult that was doing really well and then, all of the sudden, wasn’t and there was nothing we could do, that would be kind of hard”—Female, registered nurse, 3 years ICU experience

“If it’s … somebody that was not trending that direction, or it’s a very young person or, you know, a very acute change … that can definitely add to the stress.”—Female, physician, 3.5 years ICU experience

“Especially if a patient is young, it’s hard … when we see a 40-year-old, well I can certainly relate … it’s difficult.”—Female, pharmacy, 11 years ICU experience

“I think it just depends … on how invested you are in the person that you’re caring for.”—Female, physician, 5 years ICU experience

Abbreviations: ICU, intensive care unit.

^aStressors in the intensive care unit varied among interdisciplinary team members. Nurses had more stress from family member interactions and moral distress. Physicians and pharmacists accrued more stress from documentation and administrative burden. Meanwhile, most team members agreed that there was not enough time to complete their daily tasks in an effective manner, and this contributed to their stress. Additionally, codes added to work stress, especially if there were unexpected deaths or the patient was especially young.

Theme 1: Interdisciplinary Dynamics

The study institution’s ICU structure was based on a multidisciplinary team-based model; however, multiple team members reported often feeling that their opinions were not valued. Participants indicated that this inattention to their input reduced their sense of worth and autonomy. Some felt that the shared decision-making expected in a team-based model was lacking. Nonphysician team members expressed concern that their opinions were not always respected or acted on. Regarding codes, there was agreement that a code functioned best when roles were clearly defined and individuals fulfilled those roles. A lack of clear role expectations resulted in increased stress.

Theme 2: Work Stressors

Multiple factors emerged as contributing to work stress, which varied slightly by discipline. Physicians named administrative burden of documentation and lack of control of patient outcomes, whereas pharmacists identified lack of autonomy and long hours spent on responsibilities beyond direct patient care. Stress in the ICU for nurses centered on moral distress, stress related to a patient death, inflexible schedules, and interpersonal difficulties with patients or families. Representatives of nearly all disciplines stated that there was not enough time in the day to complete all the required tasks and that there was an “unrealistic workload.” Members of some disciplines, namely pharmacy, felt unsafe caring for their high patient load in the limited time frame. Most participants were also asked if they tended to bring work stress home. Five out of 9 nurses (56%), 2 out of 3 respiratory therapists (67%), and 100% of physicians and pharmacists reported bringing work stress home. However, although comments from nurses and respiratory therapists focused on bringing emotional stress home, comments from pharmacists and physicians indicated that both emotional stress and administrative tasks such as “research and paperwork for the program” invaded their home lives. Overall, members of multiple disciplines felt stress during unit codes, especially if the outcome was poor and/or the patient was young.

Discussion

We identified factors that contributed to work stress in various ICU disciplines and found that such factors varied by discipline. Physicians and pharmacists felt the burden of emotional stress as well as other stressors related to research productivity and administrative tasks. On the other hand, nurses’ and respiratory therapists’ stress tended to relate to moral distress and lack of interprofessional collaboration and perceived respect from other members of the health care team. We found that members of all disciplines felt valued when their opinions were considered. Not surprisingly, when one’s input was ignored or not taken into account, the result was increased frustration and stress and poor perceived team dynamics. Ameliorating the culture of medicine and reducing burnout in health care workers have received increasing attention in recent decades; recognizing that work stress may arise from different factors depending on discipline is crucial in this effort.^1,2

The findings of our study support previous research results identifying specific factors that contribute to work stress and burnout in physicians and nurses, such as documentation burden, long work hours, and excessive workload among physicians and moral distress, caring for families in crisis, and undesirable schedules among nurses.^1,4 Importantly, although a team-centered approach is often emphasized in the ICU setting, many nonphysician members of the health care team expressed that they often did not feel heard or respected during multidisciplinary rounds. In an environment where a patient’s condition can change in seconds, it is essential for all team members to feel comfortable voicing their concerns to ensure patient safety. A strong relationship has been found between burnout in physicians and medical errors, and it is not unreasonable to postulate that this relationship also exists in other medical disciplines.⁵ Our results indicate that creating an environment of open, respectful communication may help combat burnout, as it allows all team members to feel valued and appreciated, which may improve their sense of personal identity and accomplishment.¹¹ Thus, best practices for team communication include developing a culture of diversity, open dialogue, and receptivity to others’ opinions.

Limitations of our study include its small sample size, with only a few members from each discipline, contributing to sample bias. Furthermore, the team members were from a single institution, and their experiences may not be generalizable to all ICU environments. Strengths of the study include its evaluation of various disciplines within a single study structure, which is rare in the current body of literature on the topic of burnout. We identified important and addressable factors that may contribute to feelings of burnout in the ICU clinician team. Future studies are needed that involve more participants at multiple sites to gather more widely applicable information on this topic.

Conclusions

Multiple factors contribute to work-related stress and burnout across different professions in the ICU. Additional research is needed to further describe these factors and uncover possible solutions. Meanwhile, ICU staff members can continue to work toward improved communication and increased receptivity to the diversity of opinions inherent to the multidisciplinary team-based model of intensive care.