© 2007 American Thoracic Society doi: 10.1164/rccm.200702-194ED
Is There an Epidemic of Burnout and Post-traumatic Stress in Critical Care Clinicians?University of Washington, Seattle, Washington
University of California, San Francisco, San Francisco, California In this issue of the Journal (pp. 686–704), there are three articles examining the prevalence of burnout or psychological symptoms among critical care clinicians (1–3). These articles, appearing together in a single issue, represent a pivotal point in the research on this topic and an important opportunity for the field of critical care. In the first article, Embriaco and colleagues found that almost half of critical care physicians studied in France had high levels of burnout symptoms and almost a quarter had significant symptoms of depression (1). In the second article, Poncet and colleagues found that a third of critical care nurses studied in France had high levels of burnout symptoms and 12% had significant symptoms of depression (2). Finally, in the third article, Mealer and colleagues found that more than a quarter of critical care nurses studied in the United States had significant symptoms of post-traumatic stress disorder (PTSD) and depression; approximately 20% had significant symptoms of anxiety (3). We address three questions concerning these remarkable findings: (1) Do the results accurately describe critical care clinicians today, (2) What are the implications for critical care, and (3) Where do we go from here? There are several methodologic issues regarding these studies that should be considered. First, the response rates for these studies varied. In the two French studies, approximately 57% of eligible intensive care units (ICUs) participated and in those ICUs more than 80% of eligible physicians and nurses participated (1, 2). In the U.S. study, approximately half of the eligible nurses participated in the study (3). Since the response rates were less than 100%, there is potential for bias. If bias exists, what is its direction? It is possible that clinicians with more distress might be more motivated to participate. On the other hand, individuals with severe PTSD or burnout may be less likely to participate due to avoidance or apathy—key features of these syndromes. Although it is impossible to determine the direction or extent of bias, it seems likely that, on balance, the true prevalence of symptoms is close to these estimates. A second methodologic concern is that these studies took place in specific regions: France and Atlanta, Georgia. It is hard to know if the findings generalize to other regions. To their credit, the researchers examined multiple institutions and the combination of these three studies provides compelling evidence that this is a systemic problem that does indeed generalize to many regions. Third, these studies are cross-sectional and therefore it is not possible to assign causality to the associations identified. For example, the association between burnout and poor relationships with colleagues could be because poor professional relationships cause burnout, burnout causes poor professional relationships, or even that a third factor, such as the structure of critical care, causes both burnout and poor professional relationships. Fourth, it is important to realize that the measures used in these studies do not equate with a clinical diagnosis (such as depression or PTSD) but rather measure the burden of symptoms that can be indicative of these diagnoses. Finally, there is no definitive evidence that critical care is unique in this problem and some data suggest that these symptoms are also prevalent in areas such as oncology (4, 5), HIV care (6), and anesthesia (7). Nonetheless, we believe that these results provide compelling evidence that we have a significant problem in critical care and that the associations identified between symptoms and workplace characteristics provide directions for future studies and interventions. What are the implications of these studies? First and foremost, it is important to ascertain whether these symptoms among critical care clinicians influence the quality of care delivered to patients and their families. There is evidence that burnout among medical residents is associated with their own perceptions of decreased quality of care (8). However, we are not aware of evidence that burnout or PTSD symptoms in critical care clinicians causes decreased quality of care to patients and families. Thus, this represents an important area for future research. Nonetheless, it is hard for us to imagine that burnout, anxiety, depression, and PTSD would not be associated with decreased quality of care, especially in areas such as clinician–family communication and emotional support for patients and families. A second important implication of these studies relates to workforce issues. Both critical care medicine and nursing are faced with dramatic workforce shortages (9). We will not be able to attract and retain clinicians in critical care unless we can develop programs and policies that provide support to these clinicians and address the potential for burnout, PTSD, and poor job satisfaction among clinicians. Where do we go from here? The studies in this issue of the Journal provide some hints at the directions we should take. First, both studies from France found an association between increased burnout and worse interdisciplinary relationships in the ICU (1, 2). In other observational studies, poor interdisciplinary communication and collaboration among ICU nurses and physicians have been associated with increased patient mortality, length of stay, and readmission rates (10–13). Better nurse–physician communication has also been associated with enhanced professional relationships and learning for nurses and physicians, as well as decreased job stress for nurses (14, 15). These studies suggest that enhanced interdisciplinary collaboration may be an important target for improving quality of care as well as improving clinician psychological symptoms. Second, all three studies suggested that the structure of the work environment, such as increased work hours and decreased days off, was associated with increased symptoms among clinicians (1–3). There is growing interest in creating healthy work environments for ICU clinicians. The American Association of Critical-Care Nurses' standards for establishing and sustaining healthy work environments advocate skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership (16). The application of these standards to clinical practice could help address clinicians' psychological symptoms. Third, the French studies found associations between caring for patients at the end of life and symptoms of burnout (1, 2). Extensive research shows that conflicts over end-of-life care cause significant distress among ICU nurses (17, 18) and physicians (19). There is also recent evidence from France showing that improved communication about end-of-life care with family members reduces the prevalence of symptoms of anxiety, depression, and PTSD among the family members (20). Improvement in palliative care for patients in the ICU, especially those who die, is another important target for decreasing distress among ICU clinicians. Offering clinicians an opportunity to discuss their experiences associated with caring for dying patients and their families may also provide an important approach to address clinicians' symptoms of burnout and PTSD (21). Palliative care protocols in the ICU can provide direction to improve collaboration among ICU clinicians and reduce stress on clinicians as well as provide suggestions for "caring for the caregivers" (22, 23). The studies in this issue provide compelling evidence of significant problems that occur during the delivery of critical care to patients and their families (1–3). Although these studies do not provide clear evidence regarding the prevalence of clinically significant psychiatric disease among critical care clinicians, we believe these studies, in combination with prior studies (24, 25), provide compelling evidence that we have a significant problem in critical care that requires both further study and immediate action. These studies should serve as a call to action for researchers, funding agencies, health care organizations, and professional societies to address the mental health of critical care clinicians. We also believe such actions will improve the care received by critically ill patients and their families and do much to address the workforce shortages for critical care nurses and physicians. FOOTNOTES Conflict of Interest Statement: Neither author has a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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