Ruth Kleinpell, PhD, RN, FCCM
The increased attention being given to addressing burnout among healthcare professionals is due in part to the recognition that burnout is a consequence of physical and emotional exhaustion, depersonalization, and the stressors from working under difficult or demanding conditions. The consequences of clinician burnout are significant, with implications for workplace morale, patient safety, quality of care, and costs of care, including costs related to clinician turnover. While research has substantiated the risk of burnout for all healthcare professionals, critical care clinicians are at particular risk. A new safety primer from the Agency for Healthcare Research and Quality identifies burnout among healthcare professionals as an organizational problem in healthcare that needs to be addressed.1
Recently, the World Health Organization highlighted the inclusion of burnout in the 11th revision of the International Classification of Diseases (ICD-11) as an occupational phenomenon, not as a medical condition. As such, making organizational changes becomes a key priority area in addressing burnout prevention in clinicians. Using quality improvement methods is one such way that organizations can work to mitigate burnout. In Charles Kenney’s book The Best Practice: How the New Quality Movement Is Transforming Medicine,2 the author emphasizes that making changes in the healthcare system can improve personal health and self-improvement for the entire team. In adopting a new philosophy to improve and removing barriers to change, individual intensive care units (ICUs) and healthcare organizations can use quality improvement initiatives to target the mitigation of burnout and promotion of a healthy work culture.
Critical Care Societies Collaborative Initiatives
Ongoing work by the Critical Care Societies Collaborative (CCSC) continues to highlight the importance of measures to mitigate burnout and promote a healthy work environment. The CCSC, composed of the American Association of Critical-Care Nurses, American Thoracic Society, American College of Chest Physicians, and Society of Critical Care Medicine, published a call for action in 2016 that reviewed relevant research and addressed potential interventions for mitigating burnout.3 Building on the call for action, the CCSC sponsored the National Summit on Prevention and Management of Burnout in the ICU in 2017 with 55 invited experts in fields including psychology, sociology, integrative medicine, psychiatry, suicide prevention, bereavement support, ethics, palliative care, meditation, and mindfulness-based stress reduction, among others.
As an extension of the National Summit work, a survey was disseminated to the members of the CCSC organizations. Survey respondents reported measures such as on-campus healthy food choices, on-campus exercise or gym facilities, self-scheduling, team training, mindfulness-based stress reduction classes, staff support groups, wellness committees, and a chief wellness officer or similar organizational role, among others.
The Role of Quality Improvement
Quality improvement methods can be used to implement and evaluate the impact of measures used to promote a healthy work environment, prevent or address burnout, and promote a culture of resiliency. As quality improvement is a systematic, formal approach to the analysis of practice performance and efforts to improve practice, including burnout as a quality-of-care metric in the ICU has become an area of focus.
A number of ICU teams in the CCSC national survey reported using quality improvement initiatives to address burnout prevention in the ICU. Such measures included assessing the impact of instituting a respite room for the clinical staff, exercise challenges among the staff, or pet therapy in the unit for clinicians, as well as staff evaluations of unit-based wellness committee activities, and measuring staff satisfaction with workplace changes, including self-scheduling, respite days, and flexible vacation time.
One unit reported a staff survey indicating that many clinicians did not have time to take a meal break. Using the plan-do-study-act framework of the Institute for Healthcare Improvement, the unit instituted a daily practice of arranging lunch buddies at the beginning of each shift to ensure that all staff took time for a meal break. In follow-up staff surveys, this small measure resulted in reports of staff satisfaction. Another ICU reported implementing code lavender baskets—small lavender-scented bags with tokens of recognition—for staff to acknowledge another staff member during or at the end of a stressful day, with beneficial results, including perceptions of unit cohesiveness and support.
In using quality improvement methods to implement and evaluate the impact of initiatives, ICU clinicians can help make changes to improve the work environment. The literature on quality improvement shows that, to objectively evaluate the impact of quality improvement initiatives, data must be collected, analyzed, presented to key stakeholders, and used for making improvements. With respect to targeting measures to promote a healthy work environment, mitigate burnout, and build resiliency, focused efforts are needed, including leadership support, clinician champions, and ongoing review of the impact of the initiatives. It is essential that senior ICU staff promote a culture of quality improvement in the ICU that includes a focus on the ICU work environment for clinicians.
A number of resources exist to assist clinicians in addressing the prevention and mitigation of burnout and a healthy work environment in the ICU. These include national initiatives such as the National Academy of Medicine’s Clinician Resilience Collaborative, the American Nurses Association Healthy Nurse, Healthy Nation Grand Challenge, the American Association of Critical-Care Nurses Healthy Work Environment Framework, and the American Medical Association’s STEPS Forward program, among others.
Identifying the prevention of burnout as a quality care metric for ICU clinicians has become a priority area of focus. The culture of a practice—attitudes, behaviors, and actions—reflect how passionately the practice team embraces quality. As a result, quality improvement methods can be used to assess the impact of measures implemented to target improvements in the ICU environment designed to promote a healthy work culture and address the burnout prevention as an organizational issue.
- Agency for Healthcare Research and Quality. Patient Safety Network. Patient Safety Primer. Burnout. Last updated June 2019. Accessed September 20, 2019.
- Kenney C. The Best Practice: How the New Quality Movement Is Transforming Medicine. New York, NY: PublicAffairs; 2010.
- Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. An official Critical Care Societies Collaborative Statement: burnout syndrome in critical care healthcare professionals: a call for action. Crit Care Med. 2016 Jul;44(7):1414-1421