Battling Intensivist Burnout

The Importance of Autonomy and Performance Goals in Perceived Workload Among Behavioral Health Providers

OBJECTIVE

The authors sought to assess workplace characteristics associated with perceived reasonable workload among behavioral health care providers in the Veterans Health Administration.

METHODS

The authors evaluated perceived reasonable workload and workplace characteristics from the 2019 All Employee Survey (AES; N=14,824) and 2019 Mental Health Provider Survey (MHPS; N=10,490) and facility-level staffing ratios from Mental Health Onboard Clinical Dashboard data. Nine AES and 15 MHPS workplace predictors of perceived reasonable workload, 11 AES and six MHPS demographic predictors, and facility-level staffing ratios were included in mixed-effects logistic regression models.

RESULTS

In total, 8,874 (59.9%) AES respondents and 5,915 (56.4%) MHPS respondents reported having a reasonable workload. The characteristics most strongly associated with perceived reasonable workload were having attainable performance goals (average marginal effect [AME]=0.10) in the AES and ability to schedule patients as frequently as indicated (AME=0.09) in the MHPS. Other AES characteristics significantly associated with reasonable workload included having appropriate resources, support for personal life, skill building, performance recognition, concerns being addressed, and no supervisor favoritism. MHPS characteristics included not having collateral duties that reduce care time, staffing levels not affecting care, support staff taking over some responsibilities, having spirit of teamwork, primary care-mental health integration, participation in performance discussions, well-coordinated mental health care, effective veteran programs, working at the top of licensure, and feeling involved in improving access. Facility-level staffing ratios were not significantly associated with perceived reasonable workload.

CONCLUSIONS

Leadership may consider focusing resources on initiatives that support behavioral health providers' autonomy to schedule patients as clinically indicated and develop attainable performance goals.

Addressing Burnout among Healthcare Technology Management Professionals

This article suggests ways in which healthcare delivery organizations (HDOs) may address and mitigate burnout among healthcare technology management (HTM) professionals. Burnout is defined as a state of emotional and physical exhaustion resulting from workplace stressors. Although not intended to be a fully comprehensive empirical analysis of causes of burnout, this article discusses four likely causes for burnout that are particularly relevant to HTM professionals in HDOs: (1) gaps in developing a trained and sustainable workforce, (2) growing demand for HTM expertise across knowledge domains, (3) increasing occupational stressors related to patient safety, and (4) perceived lack of understanding of employee needs. Next, based on existing literature, the article proposes four possible solutions in response to each of these issues: (1) developing human resource planning and mentoring to ensure adequate transfer of skills and knowledge, (2) implementing ways to accomplish knowledge filtering, (3) integrating HTM workers in quality improvement initiatives, and (4) implementing employee voice practices. The article concludes by discussing the possible benefits that may be derived from implementing these solutions.

A narrative review of the physiology and health effects of burnout associated with veterinarian-pertinent occupational stressors

Chronic workplace stress and burnout are serious problems in veterinary medicine. Although not classified as a medical condition, burnout can affect sleep patterns and contributes to chronic low grade systemic inflammation, autonomic imbalance, hormonal imbalances and immunodeficiencies, thereby increasing the risks of physical and psychological ill health in affected individuals. Cultural misconceptions in the profession often lead to perceptions of burnout as a personal failure, ideas that healthcare professionals are somehow at lower risk for suffering, and beliefs that affected individuals can or should somehow heal themselves. However, these concepts are antiquated, harmful and incorrect, preventing the design of appropriate solutions for this serious and growing challenge to the veterinary profession. Veterinarians must first correctly identify the nature of the problem and understand its causes and impacts before rational solutions can be implemented. In this first part of two companion reviews, burnout will be defined, pathophysiology discussed, and healthcare and veterinary-relevant occupational stressors that lead to burnout identified.

Critical Care Pharmacists: A Focus on Horizons

Critical care pharmacy has evolved rapidly over the last 50 years to keep pace with the rapid technological and knowledge advances that have characterized critical care medicine. The modern-day critical care pharmacist is a highly trained individual well suited for the interprofessional team-based care that critical illness necessitates. Critical care pharmacists improve patient-centered outcomes and reduce health care costs through three domains: direct patient care, indirect patient care, and professional service. Optimizing workload of critical care pharmacists, similar to the professions of medicine and nursing, is a key next step for using evidence-based medicine to improve patient-centered outcomes.

Burnout symptoms and workplace satisfaction among veterinary emergency care providers

OBJECTIVES

To measure symptoms of burnout among veterinary emergency care providers (VECPs), determine how burnout symptoms among VECPs compare to human emergency care providers, and identify what demographic and workplace variables are associated with these symptoms.

DESIGN

Cross-sectional study using an online survey and convenience sampling.

SUBJECTS

A total of 1204 VECPs including mostly veterinarians and technicians.

INTERVENTIONS

An online questionnaire using the Maslach Burnout Inventory and Areas of Worklife Survey was distributed between May and July 2018 via an email list and social media. VECPs working less than part-time (<20 h/week) and incomplete survey responses were excluded.

MEASUREMENTS AND MAIN RESULTS

VECPs had higher total emotional exhaustion and depersonalization scores and lower total personal accomplishment scores compared to emergency department human healthcare professionals (P < 0.001). Subsets of VECPs with the highest burnout symptom scores included females, residents, those working in private or corporate referral hospitals, and those with off-shift duties. Workplace variables positively associated with burnout symptom scores among these groups typically included perceptions of an unmanageable workload, lack of control over work, little reward (recognition) for work, or an unfair allocation of resources at work. Conversely, VECPs working >20 years and those married or with children at home had lower burnout symptom scores. Workplace variables negatively associated with burnout symptom scores among respondents included perceptions of having a manageable workload, control over work, reward for work, or a fair allocation of resources at work. Multivariable analysis revealed that the variable most positively associated with emotional exhaustion and depersonalization was workload, whereas reward was most positively associated with personal accomplishment (P < 0.001).

CONCLUSIONS

Burnout symptom scores are higher among VECPs compared to human emergency department teams. Targeting workplace variables such as workload and reward is warranted in future studies to determine strategies for reducing burnout among VECPs.

Health and Well-Being of Intensive Care Unit Physicians: How to Ensure the Longevity of a Critical Specialty

A second epidemic of burnout, fatigue, anxiety, and moral distress has emerged concurrently with the coronavirus disease 2019 (COVID-19) pandemic, and critical care physicians are especially affected. This article reviews the history of burnout in health care workers, presents the signs and symptoms, discusses the specific impact of the COVID-19 pandemic on intensive care unit caregivers, and attempts to identify potential strategies to combat the Great Resignation disproportionately affecting health care workers. The article also focuses on how the specialty can amplify the voices and highlight the leadership potential of underrepresented minorities, physicians with disabilities, and the aging physician population.

Scoping review: Positive and negative impact of technology on clinicians

BACKGROUND

Unnecessary electronic health record (EHRs) documentation burden and usability issues have negatively impacted clinician well-being (e.g., burnout and moral distress).

PURPOSE

This scoping review was conducted by members from three expert panels of the American Academy of Nurses to generate consensus on the evidence of both positive and negative impact of EHRs on clinicians.

METHODS

The scoping review was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews guidelines.

RESULTS

The scoping review captured 1,886 publications screened against title and abstract 1,431 excluded, examined 448 in a full-text review, excluded 347 with 101 studies informing the final review.

DISCUSSION

Findings suggest few studies that have explored the positive impact of EHRs and more studies that have explored the clinician's satisfaction and work burden. Significant gaps were identified in associating distress to use of EHRs and minimal studies on EHRs' impact on nurses.

CONCLUSION

Examined the evidence of HIT's positive and negative impacts on clinician's practice, clinicians work environment, and if psychological impact differed among clinicians.

The Impact of the COVID-19 Pandemic on Mental Health and Quality of Life in COVID-19 Department Healthcare Workers in Central Greece

BACKGROUND

The pandemic crisis created conditions of insecurity and threat and brought about changes in social contacts and everyday life. Frontline healthcare workers (HCW) were mostly affected. We aimed to evaluate the quality of life and negative emotions in COVID-19 HCW and searched for factors influencing the above.

METHODS

The present study was conducted among three different academic hospitals in central Greece (04/2020-03/2021). Demographics, attitude towards COVID-19, quality of life, depression, anxiety, stress (using the WHOQOL-BREF and DASS21 questionnaire) and the fear of COVID-19 were assessed. Factors affecting the reported quality of life were also assessed.

RESULTS

The study involved 170 HCW in COVID-19 dedicated departments. Moderate levels of quality of life (62.4%), satisfaction with social relations (42.4%), working environment (55.9%) and mental health (59.4%) were reported. Stress was present in 30.6% of HCW; 20.6% reported fear for COVID-19, depression (10.6%) and anxiety (8.2%). HCW in the tertiary hospital were more satisfied with social relations and working environment and had less anxiety. Personal Protective Equipment (PPE) availability affected the quality of life, satisfaction in the work environment and the presence of anxiety and stress. Feeling safe during work influenced social relations and fear of COVID-19 Conclusion: The HCW quality of life is affected in the pandemic. Feelings of safety during work related to the reported quality of life.

Supporting Professionals in Critical Care Medicine: Burnout, Resiliency, and System-Level Change

Burnout is occurring in epidemic proportions among intensive care unit physicians and other health-care professionals-accelerated by pandemic-driven stress. The impact of burnout is far-reaching, threatening the health of individual workers, the safety and quality of care our patients receive, and eroding the infrastructure of health care in general. Drivers of burnout include excessive quantity of work (nights, weekends, and acuity surges); excessive menial tasks; incivility, poor communication, and challenges to team success; and frequent moral distress and end-of-life issues. This article provides system-based practice and individual strategies to address these drivers and improve the well-being of our team and our patients.

The negative impact of interface design, customizability, inefficiency, malfunctions, and information retrieval on user experience: A national usability survey of ICU clinical information systems in Finland

INTRODUCTION

Clinical information systems (CISs) used in intensive care units (ICU) integrate large amounts of patient data every minute, and from multiple systems and devices. Intensive care requires efficient use of information technology to acquire, synchronize, integrate, and analyze data in order to make quick decisions and implement interventions in a timely manner.

OBJECTIVES

To identify factors affecting poor user experience (UX) of CISs used in ICUs in Finland.

METHODS

Data from national Electronic Health Record (EHR) and user experience survey was undertaken in 2017. Those, who used the ICU CIS on a daily or weekly basis were asked supplementary questions and, therefore, comprise a subset of the responses reported in this article.

RESULTS

On a 4-10 scale (i.e., "Fail" to "Excellent"), the mean 'grade' for the principally used ICU CIS was 6.9 (SD 1.3) points. Of the respondents, 119 (57%) were categorized as having good UX. The factors identified as affecting poor UX of the ICU CISs related to poor interface design (OR 7.8; 95% CIs 12.5-24.1; p = 0.001), insufficient customizability (OR 7.2; 95% CIs 1.7-30.6; p = 0.008), the inefficiency of performing routine tasks (OR 4.3; 95% CIs 1.0-18.2; p = 0.044), malfunctions (OR 3.5; 95% CIs 1.2-9.6; p = 0.019), and difficulties in information retrieval (OR 3.0; 95% CIs 1.0-8.8; p = 0.044). The most commonly reported usability problems with the main EHR system and ICU CISs were also identified.

CONCLUSIONS

Overall satisfaction with the principally used ICU CIS was moderate. However, the overall grades varied significantly. Poor interface design, insufficient customizability, inefficiency, malfunctions, and difficulties in information retrieval all affect poor UX.

Workforce, Workload, and Burnout in Critical Care Organizations: Survey Results and Research Agenda

OBJECTIVES

This report provides analyses and perspective of a survey of critical care workforce, workload, and burnout among the intensivists and advanced practice providers of established U.S. and Canadian critical care organizations and provides a research agenda.

DESIGN

A 97-item electronic survey questionnaire was distributed to the leaders of 27 qualifying organizations.

SETTING

United States and Canada.

PARTICIPANTS

Leaders of critical care organizations in the United States and Canada.

INTERVENTIONS

None.

DATA SYNTHESIS AND MAIN RESULTS

We received 23 responses (85%). The critical care organization survey recorded substantial variability of most organizational aspects that were not restricted by the critical care organization definition or regulatory mandates. The most common physician staffing model was a combination of full-time and part-time intensivists. Approximately 80% of critical care organizations had dedicated advanced practice providers that staffed some or all their ICUs. Full-time intensivists worked a median of 168 days (range 42-192 d) in the ICU (168 shifts = 24 7-d wk). The median shift duration was 12 hours (range, 7-14 hr), and the median number of consecutive shifts allowed was 7 hours (range 7-14 hr). More than half of critical care organizations reported having burnout prevention programs targeted to ICU physicians, advanced practice providers, and nurses.

CONCLUSIONS

The variability of current approaches suggests that systematic comparative analyses could identify best organizational practices. The research agenda for the study of critical care organizations should include studies that provide insights regarding the effects of the integrative structure of critical care organizations on outcomes at the levels of our patients, our workforce, our work practices, and sustainability.

The effect of role-related stressors on nurses' burnout syndrome: The mediating role of work-related stress

PURPOSE

This study sought to investigate the effects of role conflict, role ambiguity, and workload on burnout syndrome among clinical nurses working in university hospitals and the mediating role of work-related stress in these effects.

DESIGN AND METHODS

Cross-sectional questionnaire-based survey was conducted. Data from 386 nurses were evaluated. The research variables were analyzed using statistical methods such as factor analysis, correlation analysis, regression analysis, Sobel tests, and bootstrapping method.

FINDINGS

It was determined that role conflict, role ambiguity, workload, and work-related stress affect nurses' burnout significantly and work-related stress has a mediator role between burnout and the independent variables.

PRACTICE IMPLICATIONS

Nurses' burnout syndrome can be prevented if managerial practices to reduce the sources of role-related stressors and work-related stress are implemented by managers.

Safety of Surgical Telehealth in the Outpatient and Inpatient Setting

New telehealth platforms and interventions have proliferated over the past decade and will be further spurred by the COVID-19 pandemic. Emerging literature examines the efficacy and safety of these interventions. Early pilot studies and trials demonstrate equivalent outcomes of telehealth interventions that seek to replace routine postoperative care in low-risk patients who have undergone low-risk surgeries. Studies are underway to evaluate interventions in higher-risk populations undergoing more complex procedures. Tele-ICU platforms demonstrate promise to provide specialized, high-acuity care to underserved areas and may also be used to augment compliance with evidence-based protocols.

Physician Well-Being in Practice

Despite a recent surge of interest in physician well-being, the discussion remains diffuse and often scattered. Lingering questions of what wellness entails, how it is personally applicable, and what can be done, remain pervasive. In this review, we focus on policy-level, institutional and personal factors that are both obstacles to wellness and interventions for potential remedy. We outline clear obstacles to physician wellness that include dehumanization in medicine, environments and cultures of negativity, barriers to wellness resources, and the effect of second victim syndrome. This is followed by proven and proposed interventions to support physicians in need and foster cultures of sustained well-being from policy, institutional, and personal levels. These include medical liability and licensure policy, peer support constructs, electronic health record optimization, and personal wellness strategies. Where sufficient data exists, we highlight areas specific to anesthesiology. Overall, we offer a pragmatic framework for addressing this critical concern at every level.

Physician Burnout: Achieving Wellness for Providers and Patients

Purpose of Review

This review summarizes the history and scope of physician burnout, and explores recent advances in its understanding. With a particular focus on physicians who have completed their training, it also explores the present and future of interventions designed to alleviate the symptoms and sequelae of burnout.

Recent Findings

Nearly 50 years since first described, burnout continues to remain a pervasive issue within anesthesia and medicine as a whole. Recent work has continued to outline risk factors and specialty-specific prevalence, and explore individual and institutional interventions to prevent and treat symptoms.

Summary

Burnout continues to impact all who work in healthcare, at all levels of training. This review highlights recent advances in our understanding of the scope, causes, and management of burnout. In light of the current COVID-19 pandemic, we hope that the national and international focus on preventing and remediating burnout will continue to expand and strengthen.

Clinical Documentation for Intensivists: The Impact of Diagnosis Documentation

OBJECTIVES

The aim of this review is to describe the interaction of clinical documentation with patient care, measures of patient acuity, quality metrics, research database accuracy, and healthcare reimbursement in order to highlight potential areas of improvement for intensivists.

DATA SOURCES

An online search of PubMed was undertaken as well as review of resources published by the American Academy of Pediatrics, the Society of Critical Care Medicine, the American Medical Association, and the Association of Clinical Documentation Improvement Specialists.

STUDY SELECTION

Selected publications included those that described coding, medical record documentation, healthcare reimbursement, quality metrics, administrative databases, Clinical Documentation Improvement programs, medical scribe programs, and various payment models.

DATA EXTRACTION

Relevant information was extracted to highlight the impact of diagnosis documentation on patient care, perceived patient severity of illness, quality metrics, and healthcare reimbursement. Query data from our hospital's Clinical Documentation Improvement program were reviewed to highlight areas of improvement within our own Division of Critical Care Medicine. Additionally, interventions to improve clinical documentation were incorporated into this review.

DATA SYNTHESIS

Available data in the literature indicate that documentation of precise diagnoses in the medical record has a positive impact on quality metrics, accuracy of administrative databases, hospital reimbursement, and perceived patient complexity. However, there is insufficient data to make conclusions regarding documentation of specific diagnoses and effects on patient care. Administrative responsibilities associated with documentation have been increasing, especially with the introduction of electronic medical records.

CONCLUSIONS

Documentation of specific diagnoses in the medical record is important in the broad context of our existing medical system but there is an associated burden in doing so. Widespread implementation of electronic medical record systems has inadvertently led to clinician dissatisfaction and burnout. Research is needed to further evaluate the impact of documentation on patient care as well as steps to decrease the associated burden.