moral distress and burnout: clinicians - critical care canada · •burnout is communicated from...
TRANSCRIPT
Moral Distress and Burnout: Clinicians Sean M Bagshaw, MD, MSc
Department of Critical Care Medicine, University of Alberta,
Edmonton, Canada
CCCF, Toronto, Canada
October 2, 2017 – 13:30 – 13:50
2017 Disclosures
•Salary support: Canada government
•Grant support: Canada/Alberta government
•Speaking/consulting: Baxter Healthcare Corp.
•Steering Committee: Spectral Medical, Inc.
•Data Safety Monitoring Committee: CytoPherx, Inc.
• I am not an expert in moral distress or burnout – I simply
work in two busy ICUs
Calgary Herald/Edmonton JournalSept. 13, 2015http://www.edmontonjournal.com/nurses+lack+resources+affecting+their+ability+properly+care+patients/11362077/story.html
Tom Blackwell, Edmonton Journal, Nov 19 2014
Moral Distress
• Definition – providers experience painful feelings and/or psychological disequilibrium that occurs in situations in which the ethically right course of action is known but cannot be acted upon
• Characterized by frustration, anger, guilt, physical symptoms and anxiety due to the perceived threat to one’s moral integrity
• The perception of compromise of one’s core values or professional obligations separates moral distress from other concepts such as emotional distress, compassion fatigue and post-traumatic stress
Major Root Causes of MDS
Hamric et al AJOB Prim Res 2012
Hamric et al AJOB Prim Res 2012
Moral Distress Score – Revised (MDS-R) Instrument
• Designed/validated for use in multiple settings across HCP disciplines
• 6 parallel versions: adult/pediatric; RN, allied health; MD
• Tool contains 21 items scored by participants across two levels:• “How often a situation arises” (frequency) (scored 0-4; 0 for never; 4 for very
frequently)
• “How disturbing [it] is when is arises” (intensity) (scored 0-4; 0 for none; 4 for great extent)
• “Frequency” and “intensity” examined each or as a composite score• fxi = frequency x intensity (for each question; scores 0-16) then summing each item
• Composite (∑fxi) to reflect overall “moral distress” score – range from 0-336.
• Design: Web-based survey using validated moral distress tool (MDS-R)
• Population/Setting: Inter-professional HCPs at a single large academic institution (Jan 2011)
• Results: 592 respondents (response ~ 22%) (MDS score ~ 77.3)
• MDS was present across all providers (RN [82.0] > MD [65.8])
• MDS negatively correlated with ethical workplace environment
• Highest ranking sources of MDS:
1. Watching patient care suffer due to lack of continuity
2. Poor communication
• MDS was higher in ICU settings (n=214; 89.0; range 2-272)
• MDS ↑ among those who left or were considering leaving their position
• Those with EOLC training – experienced higher levels of MDS compared to those without such training
Whitehead et al J Nurs Scholar 2015
Moral Distress in ICU Providers
• Highest ranking “contributing” items across MDS scores: • Costs (Provide less than optimal care due to pressures from administrators or
insurers to reduce costs)
• End-of-life care (Witness healthcare providers giving “false hope” to a patient or family)
• Age was inversely associated with MDS score (AH only)
• Experience directly associated with MDS score (RN only)
Dodek et al JCRC 2015
Professional Response Rate % (n) MDS-R score (med [IQR])
Nurse 49 (428/870) 83 (55-119)
Allied Health 47 (211/452) 76 (48-115)
Physician 44 (30/68) 57 (45-70)
Relationship between Frequency and Intensity of Disturbance
Dodek et al JCRC 2015
MDS scores largely attributed
to “intensity” or “level of
disturbance” with items
rather than “frequency”
Relationship between MDS Score and Response to Questions on Leaving the Workplace
Dodek et al JCRC 2015
MDS scores correlated with
tendency to leave ICU (both
past and present) but was only
statistically significant for
nurses
Healthcare ProfessionalMDS-R score (range 0-336)
Median [IQR] Range
Nurse/NP (n=130 [99%]) 80 (57 – 110) 5 – 246
Respiratory Therapy (n=22 [55%]) 85 (61 – 104) 0 – 267
Allied Health (n=9 [69%]) 54 (39 – 66) 0 – 66
Physician (n=8 [100%]) 66 (43 – 82) 8 – 90
Total* (n=169/193 [88%]) 78 (57 – 105) 0 – 267
Johnson-Coyle et al CJCCN 2016
• Design: Prospective cross-sectional survey – June 15-29, 2015
• Survey: integration of validated tools for MDS, BOS,
workplace satisfaction, pilot tested, clinical sensibility testing,
online usability
• Sampling Frame: All health care professionals in MAZ
CVICU
01
23
4
Le
vel o
f D
istu
rba
nce
(M
ed
ian)
43210Frequency (Median)
01
23
4
Le
vel o
f D
istu
rba
nce
(M
ed
ian)
43210Frequency (Median)
a) b)
Relationship between Frequency and Intensity of Disturbance
Johnson-Coyle et al CJCCN 2016
MDS scores again were shown to be more associated with “intensity”
or “level of disturbance” with items rather than “frequency”
Root Causes of Moral Distress Among ICU Providers
• RN/NP: Initiate extensive life-saving actions when I think they only prolong death.
• Respiratory Therapy: Follow the family’s wishes to continue life support even though I believe it is not in the best interest of the patient.
• Allied Health: Continue to participate in care for a hopelessly ill person who is being sustained on a ventilator, when no one will make a decision to withdrawal support.
• Physician: Watch patient care suffer because of lack of provider continuity.
Witness healthcare providers giving “false hope” to a patient or family.
Johnson-Coyle et al CJCCN 2016
Burnout Syndrome
• Definition – syndrome where providers lose all concern, all emotional feelings for the people they work with, and come to treat them in a detached or even dehumanized way
• Characterized by emotional exhaustion, depersonalization and decline in desire for personal achievement
• Related to occupational factors (i.e., workload, control, fairness, reward)
EXPECTIONSREALITY
Brindley et al JICM 2017
Symptoms of Burnout Syndrome
Physical Behavioral Cognitive/affective
Physical exhaustion Irritability Emotional numbness
Chronic fatigue Anger and resentment Hypersensitivity
Headaches and back pain Alienation Cynicism
Gastrointestinal problemsMarital and relationship
difficultiesApathy
Sleep disturbance Rigid thinkingHelplessness and
hopelessness
Muscular tension Self-righteousness Depression
Vulnerability to illness Increased alcohol or drug useOver-identification with
patients
Maslach Burnout Inventory for Human Services (MBI-HSS)
• The MBI is a validated tool comprised of 22 items grouped into 3 subscales:• Emotional exhaustion (EE) - measures feelings of being emotionally
overextended and exhausted by one's work
• Depersonalization (DP) - measures an unfeeling and impersonal response toward recipients of one's service, care treatment, or instruction
• Personal accomplishment (PA) - measures feelings of competence and successful achievement in one's work
• Item are answered on 7-point Likert scale ranging from “never” (0) to “daily” (6)
• Results provide 3 separate scores (one for each domain)
• A combination of high scores on EE and DP, and a low score on PA, correspond to a high level of burnout
Maslach et al Ann Rev Psychol 2001
Poncet et al AJRCCM 2007
Prevalence study in 165 ICUs in France
n=2392 surveys completed (82.3%)
Severe BOS identified in 33%.
Associated with 4 domains: i) personal characteristics (age); ii) organization factors (choose
days off); iii) quality of work relations (conflict); iv) EOLC factors (caring for a dying patient)
Embracio et al AJRCCM 2007
1-day point prevalence study in 189 ICUs in France
n=978 surveys completed (82.3%)
• BOS in 46.5% of intensivists
• Factors associated with BOS:• Female sex
• ↑ Workload
• Impaired relationships and/or
conflict
Moss et al CCM 2016
ICU EnvironmentPersonal
Characteristics
Organizational
Factors
Moral Distress
Perceived Delivery of Inappropriate Care
Compassion Fatigue
PTSD and Other
Psychological
Symptoms
Increased Rates of
Staff Leave and
AttritionDecreased Patient
Satisfaction and
Quality of Care
Burnout
Syndrome
• Maslach stated: “Imagine investigating the personality of cucumbers to discover why they had turned into pickles, without analyzing the vinegar barrels in which they’d been submerged!”
Bakker et al J Adv Nurs 2005
•Burnout is communicated from one nurse to another, both consciously and unconsciously
• In addition to unfavorable workplace environment, the prevalence of burnout complaints among colleagues contributes to explaining variance in individual nurses’ burnout levels
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
Total RN/NP RRT Allied MD
High Moderate Low
Prevalence of Burnout
Moral distress and burnout scores were positively correlated (0.31, p<0.001)
Moral distress and burnout scores were negatively correlated with workplace satisfaction (-0.37, p<0.001; -0.56, p<0.001)
Johnson-Coyle et al CJCCN 2016
Themes Contributing
to Moral Distress
End-of-Life Care
Team Commu-nication
Non-Beneficial Therapy
Complex Patients
Bed Capacity
Strain
“I have felt distress….where it has been decided to end life
saving measures for a patient and the patient and family
were not ready to accept or adjust to the decision.”
“Transferring ICU patients to the ward
hastily [prematurely] when there is no
receiving bed available to meet the OR teams
demands.”
“There is a lack of transparency regarding patient status
and likelihood of [treatment]. Progress notes are vague and
uninformative... Often the [treating] team talks to a family
and reassures them and then leaves the room….only to tell
the bedside RN that this patient is unlikely to receive
[treatment]...”
“I think sometimes we do wait to long
to make a decision on end of life care.”
“[There should be] team discussion
of [complex and] difficult cases…”
“[There should be] more frequent debriefing
sessions [and an increased ability] to understand
certain decisions being made by physicians in
regards to patient care”
“[There should be] better
communication between surgical team
and ICU team in regards to patient
prognosis, plan and information provided
to family and patient.”
“If the [team plan to do] surgery on patients
who [are at risk of poor outcome], the patient
and family need a realistic idea of their
plausible outcome and suffering. Sometimes I
feel like I'm torturing my long-term
patients.”
Moral Distress/Burnout - Emergent Themes
Johnson-Coyle et al CJCCN 2016
Intervention Type Intervention Aim Example
ICU organization Intensivist work scheduleWeekend respite for intensivists*
Shift work models*
Improve workplace environment
Comprehensive information + support program*
Change team composition
Teambuilding and job rotation Structure work shift evaluations*
Person – Practical Educational programs Educational seminars*
Communication skillsIntensive (EOLC focused) communication
strategy
Relaxation exercises Yoga*
Mindfulness Facilitated discussion groups*
Person – Personal Personality and coping EI training*
Social support and coping Facilitated peer support sessions
Counselling
Proposed Response in CVICU
1. Formation of an inter-professional committee (supported by leadership) steered by
frontline professionals (develop, implement, and evaluate strategies)
2. Evaluate the process for dissemination of patient care plans and changes to GOC status
3. “Pre-briefs” in anticipation of acute stressful unit events
4. “Pauses” immediately following acute stressful events
5. Facilitated debriefs at a later time (discretionary) – not dependent on any one team
member
6. Educational seminar series – focused on issues identified by frontline professionals (i.e.,
EOLC, LVAD support)
7. Re-evaluation (repeated surveillance)
Final Thoughts
• MDS/BOS are prevalent among ICU providers*
• Common “themes” emerge as root causes for MDS:• Care of complex patients, team communication, provision of non-
beneficial therapy, end-of-life-care and capacity strain
• ICU-wide screening can gauge the healthy well-being of professionals and workplace environment
• Effectiveness of interventions are varied – likely require:• Inter-professional engagement/acknowledgement
• Mixture of person-organization multi-faceted strategies
• Adaptation/implementation fit to local context
