Published ahead of print on January 18, 2007, doi:10.1164/rccm.200608-1184OC
© 2007 American Thoracic Society doi: 10.1164/rccm.200608-1184OC
High Level of Burnout in IntensivistsPrevalence and Associated Factors1 Medical Intensive Care Unit, Hôpital Sainte-Marguerite Teaching Hospital, Université de la Méditerranée, Marseille, France; 2 Medical Intensive Care Unit, Saint Louis Teaching Hospital, Paris, France; 3 Laboratoire de Santé Publique, Faculté de Médecine, Marseille, France; 4 Département de Sociologie, Université Victor Segalen, Bordeaux, France; and 5 Maison des Adolescents, Cochin-Port Royal Teaching Hospital, Paris, France Correspondence and requests for reprints should be addressed to Laurent Papazian, M.D., Ph.D., Medical Intensive Care Unit, Hôpital Sainte-Marguerite Teaching Hospital, Université de la Méditerranée, Marseille 13009, France. E-mail address: laurent.papazian{at}ap-hm.fr
Rationale: Professional burnout is a psychological syndrome arising in response to chronic interpersonal stressors on the job. There is the perception that intensivists are particularly exposed to stress because lives are literally in their hands. Objective: To evaluate the prevalence and associated factors (patients or organization) of burnout among physicians working in intensive care units (ICUs) (including interns, residents, fellows, and attending physicians). Methods: A 1-day national survey was conducted in adult ICUs in French public hospitals. Measurements: The level of burnout was evaluated on the basis of the Maslach Burnout Inventory (MBI). Main Results: A total of 189 ICUs participated and 978 surveys were returned (82.3% response rate). A high level of burnout was identified in 46.5% of the respondents. Ordinal logistic regression showed that female sex (odds ratio, 1.58; 95% confidence interval, 1.09 to 2.30) was independently associated with a higher MBI score. Whereas no factor related to the severity of illness of patients was retained by the model, organizational factors were strongly associated with a higher MBI score. Workload (the number of night shifts per month, a long period of time from the last nonworking week, night shift the day before the survey) and impaired relationships (such as conflict with another colleague intensivist, and/or with a nurse) were the variables independently associated with a higher MBI score. In contrast, the quality of the relationships with chief nurses and nurses was associated with a lower MBI score. Conclusions: Approximately one-half of the intensivists presented a high level of burnout. Organizational factors, but not factors related to the patients, appeared to be associated with burnout.
Key Words: intensive care unit • organizational management • conflict
Burnout has been described by Maslach and coworkers (1) as a condition in which professionals "lose all concern, all emotional feeling for the people they work with, and come to treat them in a detached or even dehumanized way." Professional burnout is a psychological syndrome arising in response to chronic interpersonal stressors on the job (2). Burnout is a problem that is specific to the work context, in contrast to depression, which tends to pervade every domain of a person's life (2). Physical illness, emotional problems, increased turnover, absenteeism (2), and poor job performance and negative attitudes in general (3) are some of the problems on a long list of difficulties that have been associated with burnout. Moreover, burnout could affect the quality of patient care (4, 5). Burnout appears to be common among practicing physicians, with rates ranging from 25 to 60% (6, 7). There is a common perception that intensivists are particularly exposed to stress because lives are literally in their hands. To our knowledge, only one study (8) has evaluated the prevalence of burnout in internal medicine intensivists (attending physicians). Coomber and coworkers (9) reported that approximately one-third of U.K. intensive care unit (ICU) doctors appeared distressed and 10% reported depressive symptoms. Most of the attention has been focused on junior doctors and their long working hours. However, there have also been reports of distress among senior hospital doctors (10, 11). Because these factors are closely linked and because few studies have previously examined this syndrome in the intensive care environment, we performed this study to assess burnout among all intensivists (interns, residents, fellows, and attending physicians). We hypothesized the following: (1) there is a high rate of burnout among intensivists; (2) burnout in intensivists could be associated with the severity of illness of patients; and (3) burnout in intensivists may be associated with organizational factors such as workload and relationships with colleagues. Some of the results of these studies have been previously reported in the form of an abstract (12).
Data Collection All directors of French adult ICUs (public hospitals) were contacted by letter in January 2004 and asked to participate in the study. Nonresponding ICU directors received an additional letter in February 2004. In the agreement form, ICU directors had to indicate whether they accepted participation in the study and were asked to give the number of physicians working in their ICU.
Survey Instrument The second document was a self-administered questionnaire for each physician working in the ICU. A covering letter outlining the purpose of the study along with a three-page questionnaire was sent to each participant. The covering letter stated that the purpose of the study was to better understand the feelings of intensivists. The letter also explained that the responses would be anonymous. The questionnaire was divided into four parts. Part 1 included basic demographic data (age, sex, marital status, number of children, religion, and time to reach their hospital), data concerning their professional activity, some questions about experiences during the past week (number of night shifts; number of their patients who died; number of decisions on withholding/withdrawing; and conflict with other intensivists, ICU nurses, or patients' families), and five questions about their situation the day of the survey: number of patients under his or her responsibility, night shift before the survey, off the day before the survey, probable death of a patient, decision on withholding/withdrawing. Two more questions were about the number of conflicts with nurses and other intensivists in 2003. Intensivists were also asked to rate their relationships with nurses, chief nurses, non-ICU physicians, and hospital management on a scale of 0 to 10. Intensivists were asked about their workload (mean number of work hours per week during the previous 6 mo, mean number of night shifts per month the previous 6 mo, time elapsed since their last week of holidays/last weekend off/last day off). Part 2 consisted of the Maslach Burnout Inventory (MBI). The MBI is a 22-item questionnaire that has been shown to be reproducible and valid (1, 2). The inventory asks respondents to indicate on a seven-point Likert scale (which does not include the word "burnout") the frequency with which they experience certain feelings related to their work during the last week preceding the day of the survey. The MBI evaluates three domains of burnout. The emotional exhaustion subscale (nine items) assesses feelings of being emotionally overextended and exhausted by one's work. The depersonalization subscale (five items) measures an unfeeling and impersonal response toward recipients of one's service, care, or treatment. The personal accomplishment subscale (eight items) assesses feelings of competence and successful achievement in one's work with people. For our study, we defined burnout as a high MBI score. For the French population, a high level of burnout is defined by an MBI score of –8 to +34, a moderate level is defined by a score from –21 to –9, and a low level of burnout is indicated by an MBI score of –45 to –22 (13). Part 3 consisted of the Centers of Epidemiologic Studies Depression Scale (CES-D) (14). Part 4 of the survey, consisting of seven questions regarding the private lives of intensivists, used a four-point categorical scale, as for the CES-D, from never to frequently.
Statistical Analysis
A total of 189 of the 318 (59.4%) French ICU directors agreed to participate (Figure 1). A total of 1,189 surveys (with a return envelope addressed to the researchers) were sent on March 6, 2004, and the survey took place on March 25, 2004. A total of 978 surveys were returned (82.3% response rate).
Characteristics Tables 1 and 2 summarize the characteristics of the ICUs and of the respondents. Attending physicians constituted 62% of the sample with the remainder (38%) being residents, interns, or fellows. The majority of intensivists (54%) worked in teaching hospitals. The mean age was 40 ± 10 years and 72% of the respondents were male.
Prevalence of Burnout and Associated Symptoms Using the MBI, a high level of burnout was identified in 46.5% of the respondents. As for the remaining respondents, 23.3% of them presented a low level of burnout and 30.2% indicated a moderate level of burnout. Depersonalization (for medical professionals, a score of 10 or more is considered high, indicating burnout) was observed in 37% of the responding intensivists. A high level of emotional exhaustion (a score of 27 or more is considered high) was present in 19% of the respondents. A low level of personal accomplishment (this subscale has an inverse relationship to burnout, and a score of 33 or less is considered low) was found in 39% of the 978 intensivists who responded to the survey (1). Figure 2 presents the three MBI subscales according to the level of burnout. Intensivists presenting a high level of burnout exhibited higher emotional exhaustion and depersonalization scores associated with the lower personal accomplishment score.
In all, 39.5% of the respondents wanted to leave their jobs. This percentage was higher (51.4%) for the intensivists exhibiting a high level of burnout (Figure 3). When the CES-D score was considered, symptoms of depression were identified in 24% of the intensivists and 80.6% of the intensivists exhibiting symptoms of depression presented a high level of burnout. Higher levels of burnout were associated with a poor quality of private life (see Figure E1 in the online supplement).
Risk Factors for Burnout: Univariate Analysis Demographics. (For a summary of demographic factors associated with burnout, see Table 3.) Female intensivists reported a higher level of burnout than did male intensivists. Young intensivists having less ICU practice presented a higher level of burnout. Respondents who reported a higher level of burnout were less frequently married or partnered and more often did not have children.
Severity of illness of patients. (For a summary of factors associated with the severity of illness of patients and their relationship to burnout, see Table 3.) SAPS II score, mortality rate, patient deaths, and decision to withhold or withdraw treatment during the week preceding the survey had no impact on burnout (Table 3). A decision to withhold or withdraw treatment the day of the survey was the sole factor associated with a higher level of burnout.
Organizational factors.
Relationships were related to burnout. Indeed, higher levels of burnout were associated with conflicts with nurses, colleagues, or patients' families during the previous 7 days. The number of conflicts with both nurses and other intensivists was also related to the level of burnout. Finally, relationships with nurses, chief nurses, employers or non-ICU physicians were worse for ICU physicians experiencing a high level of burnout (Figure 4).
Risk Factors for Burnout: Multivariate Analysis
Burnout appears to be common among practicing physicians, with rates ranging from 25 to 60% (6, 7, 16–19). In a study concerning 253 members the Section of Internal Medicine of the Society of Critical Care Medicine, when MBI subscales were considered, Guntupalli and Fromm (8) found that the emotional exhaustion subscale score was 22.2 ± 9.5, the depersonalization score was 7.1 ± 5.1, and the personal accomplishment score was 30.9 ± 6.4. Whereas depersonalization was similar, personal accomplishment (36.6 ± 7.1) was higher and emotional exhaustion (17.2 ± 10.4) was lower in the present study. In a French study concerning 306 general practitioners, the emotional exhaustion subscale score was 21.9 ± 12.4, the depersonalization score was 9.1 ± 6.7, and the personal achievement score was 38.7 ± 7.1 (20). A high level of emotional exhaustion was found in 26% of the responders (19% in the present study) and a high level of depersonalization was noted in 34% (37% in the present study) (20). Finally, the major difference from this latter study performed in general practitioners was the low level of personal accomplishment, which was much more frequently identified in the present study (19 vs. 39%, respectively). However, the total MBI score was not provided in the study done by Cathebras and coworkers (20). Caring for acutely ill patients may lead to the burnout syndrome. In our study, patient characteristics (SAPS II score, mortality rate, and decision to withhold or withdraw treatment) were not associated independently with a higher level of burnout. In contrast with the study by Baldwin and coworkers (21), we did not find a correlation between the mortality rate among patients and the degree of burnout. Among the demographic factors, only female sex was retained by the model. A U.S. representative random stratified sample of nearly 6,000 physicians in primary and nonsurgical care showed that female physicians were 60% more likely than male physicians to report signs or symptoms of burnout. This is in agreement with the findings of the present study. Contrary to expectation, none of the 15 studies on residents reviewed by Thomas (22) has demonstrated a higher risk or differential effect of burnout for women. However, only 4 of the 15 studies reported burnout by sex. In the present study, we did not find an association with age, work experience, marital status, number of children, or other personal factors. It is important to point out that French residents and interns undergo training in ICUs during contiguous 6-month periods. The day of the survey (March 25, 2004), they had been working in the same ICU since November 1, 2003. It is possible that older intensivists had stopped working in an ICU because of a high level of burnout and did not participate in the survey. We found that overall workload is associated with higher MBI scores, except when only attending physicians were considered (see the online supplement). For Maslach and colleagues (2), burnout is a response to overload. Generally, workload is related to the emotional exhaustion dimension. In the present study, the multivariate analysis identified three factors for burnout: the number of night shifts per month, a long period of time from the last nonworking week, and performance of a night shift before the survey. In contrast, the number of working hours per week was not retained by the model. For Gopal and colleagues, reducing hours may be the first step to reduce resident burnout (23). The present study showed that conflicts with coworkers (with another intensivist or nurses) were associated with the higher level of burnout. In contrast, the quality of the relationships with nurses and chief nurses was also associated with a lower degree of burnout. For Stehle (24), many of the stressors identified concerned working relationships between nurses and doctors. For young Swiss physicians (residents and chief residents), the most important job expectations were good relationships with colleagues (25). One of the limitations of the present study is that although some variables were collected at the level of the ICU (e.g., SAPS II score and mortality rate), we did not use an analytic approach that incorporated a clustered study design. Our aim was to focus on the individuals (doctors) rather than on the ICUs themselves. Finally, no factor obtained at the level of the ICU was retained by the univariate analysis to be entered in the model when multivariate analysis was performed. Another limitation is that we performed an observational study, which cannot determine a causal relationship between some of the variables. Concerning the statistical analysis, although there are a large number of statistical tests, the p values were not corrected for multiple comparisons. Previous investigations in a wide variety of settings have shown that burnout may affect performance (26) and quality of medical services (4). In a study on medical residents, a high depersonalization score was associated with self-reported suboptimal patient care practices (5). Burnout has been associated with various forms of job withdrawal–absenteeism, intention to leave the job, and turnover. In the present study, about 50% of the intensivists exhibiting a high level of burnout wish to leave their jobs. However, for people who stay on the job, burnout leads to lower productivity and effectiveness at work. Consequently, it is associated with decreased professional satisfaction and reduced commitment to the job or the organization (2). Changing the working conditions and managing professional conflicts are essential for dealing with burnout. In a study concerning anesthesiologists, improving work organization (presence of skilled assistance in the operating theater) was the most important factor leading to reduced burnout (27). For Thomas, restricting work hours alone is not associated with a reduction in burnout (22).
Supported by a grant from the Assistance Publique Hôpitaux de Marseille. This article has an online supplement, which is accessible from this issue's table of contents at www.atsjournals.org Originally Published in Press as DOI: 10.1164/rccm.200608-1184OC on January 18, 2007 Conflict of Interest Statement: None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.
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AT A GLANCE COMMENTARY
0.001 (high level of burnout vs. low and moderate).
