Burnout syndrome among critical care healthcare workers Nathalie Embriaco, Laurent Papazian, Nancy Kentish-Barnes, Frederic Pochard and Elie Azoulay

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1 Burnout syndrome among critical care healthcare workers Nathalie Embriaco, Laurent Papazian, Nancy Kentish-Barnes, Frederic Pochard and Elie Azoulay Purpose of review Burnout syndrome is a psychological state resulting from prolonged exposure to job stressors. Because ICUs are characterized by a high level of work-related stress, a factor known to increase the risk of burnout syndrome, we sought to review the available literature on burnout syndrome in ICU healthcare workers. Recent findings Based on most recent studies, severe burnout syndrome (as measured using the Maslach Burnout Inventory) is present in about 50% of critical care physicians and in one third of critical care nurses. Strikingly, determinants of burnout syndrome are different in the two groups of caregivers. Namely, intensivists who have severe burnout syndrome are those with a high number of working hours (number of night shifts and time from last vacation) but determinants of severe burnout syndrome in ICU-nurses are related to ICU organization and end-of-life-related characteristics. ICU conflicts, however, were independent predictors of severe burnout syndrome in both groups. Summary Recent studies reported high levels of severe burnout syndrome in ICU healthcare workers and identified potential targets for preventive strategies such as ICU working groups, communication strategies during end-of-life care and prevention and management of ICU conflicts. Keywords conflicts, depression, end-of-life care, exhaustion, intensive care Curr Opin Crit Care 13: ß 2007 Lippincott Williams & Wilkins. Intensive Care Unit, Saint-Louis and Sainte Marguerite Teaching Hospitals, Assistance Publique Hôpitaux de Paris, University Paris 7, Paris and Assistance Publique, Hôpitaux de Marseille, Marseille, France Correspondence to Élie Azoulay, MD, PhD, Service de Réanimation Médicale, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, Paris, France Tel: ; fax: ; elie.azoulay@sls.ap-hop-paris.fr Current Opinion in Critical Care 2007, 13: Abbreviations BOS burnout syndrome IQR interquartile range MBI Maslach Burnout Inventory ß 2007 Lippincott Williams & Wilkins Introduction Burnout is a psychological term (concept) for the experience of long-term exhaustion and diminished interest (depersonalization or cynicism), usually in the work context. Burnout is often construed as the result of a period of expending too much effort at work while having too little recovery. Healthcare workers are often prone to burnout. Still, burnout can affect workers of any kind, including students. High stress jobs can lead to more burnout than lower stress work. Burnout syndrome (BOS) [1] was identified in the early 1970s in human service professionals, most notably healthcare workers [2]. BOS has been described as an inability to cope with emotional stress at work [3] or as excessive use of energy and resources leading to feelings of failure and exhaustion [4]. Clinical symptoms of BOS are nonspecific and include tiredness, headaches, eating problems, insomnia, irritability, emotional instability, and rigidity in relationships with other people. The most well studied measurement of burnout in the literature is the Maslach Burnout Inventory (MBI). Maslach and her colleague Jackson [2] first identified the construct burnout in the 1970s, and developed a measure that weighs the effects of emotional exhaustion, depersonalization (negative or cynical attitudes toward patients), and reduced sense of personal accomplishment. This indicator has become the standard tool for measuring burnout in research on the syndrome. People who experience all three symptoms have the greatest degree of burnout, although emotional exhaustion has been identified as the hallmark of burnout [5,6]. Wide variations in the prevalence of BOS in healthcare professionals have been reported across specialties, both in doctors [7] and in nurses [8]. Workplace climate and workload were determinants of BOS [9]. Higher levels of severe BOS, however, were found in oncologists [10], anaesthesiologists [11], physicians caring for patients with AIDS [12], and physicians working in emergency departments [13]. ICUs are characterized by a high level of work-related stress [14], a factor known to increase the risk of BOS [15]. High rates of severe BOS were reported in ICU nurses as early as 1987 [16]. BOS is associated with decreased well being among nursing staff members [17], decreased quality of care [18 20], and costs related to absenteeism and high turnover [21], all of which have particularly 482

2 Burnout syndrome Embriaco et al. 483 devastating consequences in the ICU. Few studies have addressed the prevalence and determinants of BOS in ICUs. A study based on the MBI showed a high rate of BOS among ICU physicians, with determinants related to both patient care and inadequate support [22]. Similarly, studies in ICU nurses indicated that BOS was common and preventive strategies were urgently needed [23,24]. In addition, recent ICU studies have highlighted important levels of ICU burden in critical care nurses. Mealer and colleagues [25 ] surveyed 351 ICU and general nurses from three different hospitals and then surveyed 140 ICU nurses. Anxiety and depression were common in both groups. ICU nurses, however, had an increased prevalence of posttraumatic stress disorder (PTSD) symptoms when compared with other general nurses [25 ]. Our study group recently conducted two large longitudinal studies in France [26,27 ]. We surveyed 978 intensivists and 2392 critical care nurses. Approximately one-half of the intensivists and one third of the nurses reported a high level of burnout. The determinants of burnout were different in intensivists and nurses. In this study we will review data from the literature on burnout syndrome in critical care healthcare workers. Our main objective is to emphasize that a significant part of burnout is preventable and that some of the determinants of severe burnout are amenable to preventive strategies. Defining the burnout syndrome As stated above, the concept of burnout describes the relationships that people have with their job especially among people working in human services and healthcare [1,4,6]. Burnout is a psychological state resulting from prolonged exposure to job stressors. According to Maslach and colleagues [2], this syndrome is specific to the work context in contrast with depression which concerns professional and private life. BOS has three dimensions: emotional exhaustion, depersonalization (or cynicism) and a sense of low personal accomplishment (Fig. 1) [6]. Emotional exhaustion is the key component of BOS. The symptoms of burnout are nonspecific and include irritability, emotional instability, rigidity in relationships with colleagues and organic complaints such as eating problems, tiredness or sleep disorders. The MBI is a 22-item questionnaire developed by Maslach et al. [6] for measuring the severity of burnout. The inventory asks respondents to indicate on a sevenpoint Likert scale the frequency with which they experience certain feelings related to their job. Maslach characterizes three levels of burnout: low, moderate and high. The MBI evaluates the three domains of the BOS by independent subscales. It is the most widely employed measure and has high reliability and validity. According to the studies, burnout is defined by a high score of depersonalization subscale or a high score of emotional exhaustion subscale [18] or a high total score [26,27 ]. Burnout occurs primarily in care professions including physicians [28,29], nurses [30,31] or educators. Over the past 20 years, several studies reported a high prevalence rate of burnout in healthcare professionals, both in doctors and in nurses. In a survey of psychiatric nurses, 42% of respondents exhibited a high level of emotional Figure 1 Distribution of the three different subscales explored by the Maslach Burnout Inventory questionnaire in French intensivists Adopted with permission from American Thoracic Society [26 ].

3 484 Critical care outcomes exhaustion [31]. Burnout is frequent among physicians with rates ranging from 25 to 60% [28,32 36], depending on the working conditions and medical specialty [7,29]. Studies of burnout in practicing physicians have shown that burnout can develop at any stage in the career of a physician [28,32]. In a study focused on internal medicine residents, 76% of respondents met a high level of BOS [18]. Determinants of burnout consist of job characteristics, demographic variables (sex, age) and personality traits. Many aspects of professional practice have changed for both doctors and nurses and include lack of autonomy, decreased resources and the requirement of a high level of competence and technical support [14]. Workload, stressful work environments like intensive care units [14,37], severity of illness [38] and conflicts with coworkers or with patients, may be risk factors for BOS [26,27 ]. Burnout among intensivists The first study to evaluate ICU physicians included 253 members of the Section of Internal Medicine of the Society of Critical Care Medicine [22]. The authors [22] reported high emotional exhaustion and depersonalization MBI subscale scores, and a decreased personal achievement subscale score. In a recently published survey [26 ] performed in French intensivists (interns, residents, fellows and attending physicians), a high level of burnout was identified in 46.5% of the respondents. Depersonalization (for medical professionals, a score 10 is considered high, indicating burnout) was observed in 37% of the responding intensivists. A high level of emotional exhaustion (27 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 33 is considered low) was found in 39% of the 978 intensivists who responded to the survey [26 ]. This latter study did not identify age as an independent associated factor of presenting a high level of burnout [26 ] whereas in physicians working for health maintenance organizations, older physicians had lower reported levels of burnout [39]. Biaggi and coworkers [40], however, found that 43% of chief residents and 41% of residents from Swiss public primary and secondary referral centers and teaching hospitals met the critical values for emotional exhaustion. Among the demographic factors, female sex appeared to be associated with a higher rate of burnout. In the study conducted in French adult ICUs from public hospitals, only female sex was shown to be an independent risk factor for burnout [26 ]. A representative, random stratified sample of nearly 6000 US physicians in primary and non surgical care showed that female physicians were 60% more likely than male physicians to report signs or symptoms of burnout [41]. Workload is usually associated with burnout. The workload of ICU physicians is physically demanding, allows limited rest and is associated with sleep deprivation and objective markers of physiologic stress (ketonuria, arrhythmia or heart rate abnormalities) [42]. The French survey reported that the number of on-duties per month, a long delay from the last nonworking week, and being on duty the day before the survey were associated with a higher level of MBI score [26 ]. Also, poor work organization is associated with more stress and produces burnout. In the study by Shanafelt et al. [18] performed in internal medicine residents, frequent 24-h shifts as well as inadequate leisure time appeared as major stressors and were associated with a high level of burnout. Ramirez et al. showed that workload and lack of adequate resources emerged as important stressors for medical specialists [7]. Patient characteristics did not appear as independent risk factors. In contrast to the study of Baldwin and co-workers [43], who found a correlation between the number of deaths on the ward and a perception of being overwhelmed, the degree of burnout is not correlated to the mortality rate among patients included in the study on French intensivists. As shown in Table 1, it has been reported that conflicts with co-workers (with another intensivist or with a nurse) are associated with a higher level of burnout [26 ]. In contrast, having good relationships with nurses appeared to be a protective factor [26 ]. Relationships between nurses and doctors have been identified [44] as stressors in critical care physicians and nurses for a long time. For young Swiss physicians (residents and chief residents), the most important job expectations were Table 1 Independent risk factors associated with a higher level of burnout in critical care nurses Odds ratio 95% Confidence interval P value Respondent s age (per additional year) Able to schedule days off according to personal wishes Participates in an ICU research group Conflicts with patients Grade (1 10) given to the relationship with head nurses Grade (1 10) given to the relationship with physicians Respondent caring for a dying patient Number of decisions to forgo life sustaining therapies in the last week Reproduced with permission [27 ].

4 Burnout syndrome Embriaco et al. 485 good relationships with colleagues [40]. In a crosssectional study of orthopedic residents [45], depersonalization was significantly associated with stress in relationships with nurses and their colleagues. Studying the links between stress and burnout in UK physicians, McManus and colleagues [46] showed that there is a causal cycle in which emotional exhaustion makes doctors more stressed and stress makes doctors more emotionally exhausted. Burnout among critical care nurses In a longitudinal study in France, we have surveyed 2497 nursing staff members working in 165 ICUs [27 ]. Of these, 2392 respondents returned a complete MBI questionnaire. Among the respondents, time from nursing school graduation to questionnaire completion was a median of 40 months [interquartile range (IQR), months], and time in the ICU was 36 months (IQR, months). Work schedule was 16 days (IQR, days) per month, 10 h (IQR, 8 12 h) per day, and 36 h (IQR, h) per week. Patient nurse ratio was 3 (IQR, 3 3). Severe BOS (MBI < 9) was identified in one third of the respondents. As reported in Table 2, four groups of characteristics were independently associated with severe BOS and included personal characteristics of the respondent, such as younger age; organizational factors, such as receiving days off as requested and participation in an ICU working group; quality of working relationships, such as conflicts with patients, relationship with head nurses and physicians and end-of-life-related factors, such as caring for a dying patient and larger number of decisions to forgo life-sustaining treatments within the last week. Figure 2 reports the relationship between the MBI score and the end of life-related factors. These results highlight how the ICU is a highly stressful work environment and may, therefore, be associated with a high rate of BOS in staff members [14,16]. Because BOS was associated with decreased quality of care [18,47], absenteeism and high turnover rates [21], and poor communication with families [18,48], looking for determinants of BOS may offer opportunities to identify preventive strategies. In our study [27 ], both personal characteristics and work-related factors were associated with BOS. Job satisfaction is increased when individuals receive positive feedback indicating that their work is valued and significant. Interventions such as ICUresearch groups, stress management workshops, and training in communication and stress management should be evaluated for critical care nurses to demonstrate how effective they are and whether they should be routinely implemented in ICUs. In addition, perceived conflicts with patients, families, or other staff members increased the risk of BOS. Emotional exhaustion is a direct consequence of conflict that leads to depersonalization and to loss of a sense of personal accomplishment [2]. In our study, both perceived conflicts and perceived poor relationships with other staff members were strong independent risk factors for severe BOS. Preventing conflicts and improving communication in the ICU may therefore decrease the risk of BOS. Several studies identified differences between ICU nurses and physicians regarding the provision of futile care [49] or the assessment of treatment goals [50,51]. In our study, caring for a dying patient and a larger number of decisions to forgo life-sustaining therapies (DFLSTs) were independent determinants of BOS. In recent years, considerable effort has been expended to improve end-of-life care [52], improve communication, and share discussions and decisions with patients and family members in the ICU [53]. Our results suggest a need for expanding these efforts to the nursing staff [15,24,49,54]. Intensive communication between nurses and physicians about DFLSTs may help nurses feel that the work they do is valued and escape from feelings of guilt [54]. Consequences and management of burnout syndrome Burnout is associated with a lower effectiveness at work, a decreased job satisfaction and a reduced commitment to the job or the organization [2]. It is associated with intention to leave one s job. In recent French studies, about 50% of intensivists and 60% of intensive care nurses who exhibited a high level of burnout, wished to leave their jobs [26,27 ]. Symptoms of depression (measured by the Center for Epidemiological Studies Table 2 Independent risk factors associated with a higher level of burnout in intensivists High level of burnout n ¼ 455 Moderate level of burnout n ¼ 295 Low level of burnout n ¼ 228 Univariate OR (95% CI) Multivariate Women (%) ( ) 0.02 Night shifts per month, number ( ) 0.02 Night shift before the survey (%) ( ) 0.03 Period since the last nonworking week (days) 42 (20 90) 35 (17 89) 30 (21 85) ( ) 0.02 Conflict with a nurse (%) ( ) 0.04 Conflict with a colleague intensivist (%) ( ) Relationships with nurses (0 10 rating scale) ( ) Relationships with chief nurses (0 10 rating scale) ( ) Reproduced with permission from American Thoracic Society [27 ].

5 486 Critical care outcomes Figure 2 Impact of factors related to end-of-life care on the Maslach Burnout Inventory score From bottom to top, the five horizontal lines in each box plot indicate the 10th, 25th, 50th (median), 75th, and 90th percentiles. DFLST, decision to forgo life-sustaining treatments. Adapted with permission [27 ]. Maslach Burnout Inventory score All respondents One DFLST More than One death over one DFLST the last seven days More than one death over the last seven days Scale for Depression) and poor quality of private life are more common in French intensivists and intensive care nurses with severe burnout [26,27 ]. Absenteeism and job turnover are increased [55]. Burnout may affect job performances [56] and quality of patient care [57]. In a study concerning internal medicine residents, Shanafelt et al. [18] found a relationship between high level of depersonalization and poorer patient care practices. Moreover, high levels of nurse burnout are correlated with patient dissatisfaction [58]. People who are experiencing burnout can have a negative impact on their colleagues, both by causing greater personal conflict and by disrupting job tasks [2]. The performance of an ICU depends on cultural aspects (which consider the normative beliefs shared by a group of health workers), managerial practices and individual well being, including burnout, job satisfaction and intention to quit [59]. Predicting and preventing burnout syndrome in intensive care units should be a priority. With the exception of demographic factors, professional relationships and working conditions can be improved. The objective is to reduce stressors. Individual strategies have been proposed to prevent burnout. They include stress inoculation training, relaxation, time management, assertiveness training, rational emotive therapy, training in interpersonal and social skills, teambuilding and meditation [2]. The aim is to enhance the capacity of workers to cope with the demands of their jobs. In a study concerning nurses, personal stress management approaches were proposed for preventing burnout [60]. McCue and Sachs [61] described a half-day stress management workshop in which they trained medicine and pediatrics residents from a teaching hospital in personal management, relationship, outlook, and stamina skills. They concluded that such a management workshop was received positively and improved stress and burnout test scores [61]. Even if Maslach showed that individual-oriented approaches may help people to alleviate emotional exhaustion, they cannot act on the two other components of burnout [2]. Workload is an independent risk factor for developing burnout [18,26 ]. In a study concerning anesthetists, improving work organization (presence of skilled assistance in the operating theatre) was the most important factor able to reduce stress [62]. For Gopal and colleagues [63], work hour restrictions may be the first step to prevent burnout. In intensive care units, reducing interns work hours can reduce serious medical errors [64]. Restricting work hours alone, however, is insufficient [47]. The quality of relationships with co-workers appears to be a protective factor against burnout, both in nurses and in doctors [26,27 ]. Physicians and nurses differ in their perception about teamwork climate: physicians appear to be more satisfied with nurse physician collaboration and communication than are nurses [50]. Improving communication and managing conflicts are essential to prevent burnout. In the French survey concerning intensive care nurses, end of life related factors and a larger number of decisions to forgo life-sustaining treatments were independent risk factors for the development of severe burnout. Staff meetings between nurses and doctors and the presence of a full time psychologist were not associated with a reduction of severe burnout [27 ], suggesting a need for evaluating

6 Burnout syndrome Embriaco et al. 487 and improving debriefing techniques [65]. Moreover, Ferrand and colleagues [49] showed the existence of discrepancies in the perception of end-of-life-care between physicians and nurses. Intensive communication about decisions at end of life between nursing staff and physicians may improve well being at work. The support from co-workers may help employees to create a better sense of community that can help reduce burnout [48]. Institutional factors that contribute to well being include facilitating a collegial work environment, promoting physician autonomy and providing adequate office resources and support staff [48]. For nurses, factors which would alleviate stress are more support and appreciation from senior staff and more social contact with colleagues [30]. People may be able to tolerate greater workload if they value their work and feel they are doing something important. For example, participating in a research group decreases the risk of severe burnout in ICU nurses [27 ]. Conclusion Burnout syndrome may be considered a marker of the health of the caregiver team. Indeed, severe BOS is frequent in critical care physicians and nurses, has an important impact on daily quality of life and may threaten patient care. Moreover, several determinants of severe burnout are related to ICU organization, duration of working hours, conflicts within the ICU, communication among healthcare workers, and the management of end-of-life care. Further studies are needed to target those risk factors for BOS that were identified in observational studies and to look for and evaluate potential preventive strategies. Over the next decade, we believe that BOS should be acknowledged as an important outcome measure in clinical research. Future work should use the prevalence of BOS to evaluate strategies to manage ICU conflicts and the implementation of staff-level communication during end-of-life care. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 609). 1 Goldberg R, Boss RW, Chan L, et al. Burnout and its correlates in emergency physicians: four years experience with a wellness booth. Acad Emerg Med 1996; 3: Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001; 52: Pines A, Maslach C. Characteristics of staff burnout in mental health settings. Hosp Community Psychiatry 1978; 29: Freudenberger H. The staff burn-out syndrome in alternative institutions. Psychotherapy: Theory, Research and Practice 1975; 12: Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory Manual. 2nd ed. Palo Alto: Consulting Psychologists Press; Maslach C, Jackson S, Leiter MP. Maslach Burnout Inventory Manual. Palo Alto: Consulting Psychologists Press; Ramirez AJ, Graham J, Richards MA, et al. Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet 1996; 347: Lu H, While AE, Barriball KL. Job satisfaction among nurses: a literature review. Int J Nurs Stud 2005; 42: McManus IC, Keeling A, Paice E. Stress, burnout and doctors attitudes to work are determined by personality and learning style: a twelve year longitudinal study of UK medical graduates. BMC Med 2004; 2: Lyckholm L. Dealing with stress, burnout, and grief in the practice of oncology. Lancet Oncol 2001; 2: Nyssen AS, Hansez I, Baele P, et al. Occupational stress and burnout in anaesthesia. Br J Anaesth 2003; 90: Lert F, Chastang JF, Castano I. Psychological stress among hospital doctors caring for HIV patients in the late nineties. AIDS Care 2001; 13: Weibel L, Gabrion I, Aussedat M, Kreutz G. Work-related stress in an emergency medical dispatch center. Ann Emerg Med 2003; 41: Donchin Y, Seagull FJ. The hostile environment of the intensive care unit. Curr Opin Crit Care 2002; 8: Bakker AB, Le Blanc PM, Schaufeli WB. Burnout contagion among intensive care nurses. J Adv Nurs 2005; 51: Soupios MA, Lawry K. Stress on personnel working in a critical care unit. Psychiatr Med 1987; 5: Aiken LH, Clarke SP, Sloane DM, et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002; 288: Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002; 136: Arnedt JT, Owens J, Crouch M, et al. Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion. Jama 2005; 294: Lockley SW, Cronin JW, Evans EE, et al. Effect of reducing interns weekly work hours on sleep and attentional failures. N Engl J Med 2004; 351: Ackerman AD. Retention of critical care staff. Crit Care Med 1993; 21 (9 Suppl):S394 S Guntupalli KK, Fromm RE Jr. Burnout in the internist intensivist. Intensive Care Med 1996; 22: Sawatzky JA. Stress in critical care nurses: actual and perceived. Heart Lung 1996; 25: Chen SM, McMurray A. Burnout in intensive care nurses. J Nurs Res 2001; 9: Mealer ML, Shelton A, Berg B, et al. Increased prevalence of posttraumatic stress disorder symptoms in critical care nurses. Am J Respir Crit Care Med 2007; 175: In this study, 351 ICU and general nurses and 140 ICU nurses were surveyed. Anxiety and depression were common in both groups. ICU nurses, however, had an increased prevalence of posttraumatic stress disorder symptoms when compared with other general nurses. 26 Embriaco N, Azoulay E, Barrau K, et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med 2007; 175: In this survey performed in 978 French intensivists, a high level of burnout was identified in 46.5% of the respondents. Depersonalization was observed in 37% of the responding intensivists. A high level of emotional exhaustion was present in 19% of the respondents. A low level of personal accomplishment was found in 39% of the intensivists who responded to the survey. 27 Poncet MC, Toullic P, Papazian L, et al. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med 2007; 175: In this longitudinal study, 2497 nursing staff members working in 165 ICUs were surveyed. Severe BOS was identified in one third of the respondents. Four groups of characteristics were independently associated with severe BOS, namely, personal characteristics of the respondent (younger age); organizational factors (days off scheduled as wished and participation in an ICU working group); quality of working relationships (conflicts with patients, relationship with head nurses and physicians); and end-of-life-related factors (caring for a dying patient and larger number of decisions to forgo life-sustaining treatments within the last week). 28 Ramirez AJ, Graham J, Richards MA, et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer 1995; 71: Visser MR, Smets EM, Oort FJ, De Haes HC. Stress, satisfaction and burnout among Dutch medical specialists. Cmaj 2003; 168: McGrath A, Reid N, Boore J. Occupational stress in nursing. International Journal of Nursing Studies (1989), 26, Int J Nurs Stud 2003; 40: Kilfedder CJ, Power KG, Wells TJ. Burnout in psychiatric nursing. J Adv Nurs 2001; 34:

7 488 Critical care outcomes 32 Lemkau J, Rafferty J, Gordon R Jr. Burnout and career-choice regret among family practice physicians in early practice. Fam Pract Res J 1994; 14: Keller KL, Koenig WJ. Management of stress and prevention of burnout in emergency physicians. Ann Emerg Med 1989; 18: Deckard GJ, Hicks LL, Hamory BH. The occurrence and distribution of burnout among infectious diseases physicians. J Infect Dis 1992; 165: Gallery ME, Whitley TW, Klonis LK, et al. A study of occupational stress and depression among emergency physicians. Ann Emerg Med 1992; 21: Grassi L, Magnani K. Psychiatric morbidity and burnout in the medical profession: an Italian study of general practitioners and hospital physicians. Psychother Psychosom 2000; 69: Le Blanc PM, de Jonge J, de Rijk AE, Schaufeli WB. Well being of intensive care nurses (WEBIC): a job analytic approach. J Adv Nurs 2001; 36: Baldwin PJ, Dodd M, Wrate RM. Young doctors health: II. Health and health behaviour. Soc Sci Med 1997; 45: Freeborn D. Satisfaction, commitment, and psychological well being among HMO physicians. West J Med 2001; 174: Biaggi P, Peter S, Ulich E. Stressors, emotional exhaustion and aversion to patients in residents and chief residents what can be done? Swiss Med Wkly 2003; 133: McMurray J, Linzer M, Konrad T, et al. The work lives of women physicians results from the physician work life study. The SGIM Career Satisfaction Study Group. J Gen Intern Med 2000; 15: Parshuram C, Dhanani S, Kirsh J, Cox P. Fellowship training, workload, fatigue and physical stress: a prospective observational study. CMAJ 2004; 170: Baldwin PJ, Dodd M, Wrate RW. Young doctors health: I. How do working conditions affect attitudes, health and performance? Soc Sci Med 1997; 45: Stehle JL. Critical care nursing stress: the findings revisited. Nurs Res 1981; 30: Sargent MC, Sotile W, Sotile MO, et al. Stress and coping among orthopaedic surgery residents and faculty. J Bone Joint Surg Am 2004; 86A: McManus IC, Winder BC, Gordon D. The causal links between stress and burnout in a longitudinal study of UK doctors. Lancet 2002; 359: Thomas NK. Resident burnout. JAMA 2004; 292: Shanafelt TD, Sloan JA, Habermann TM. The well being of physicians. Am J Med 2003; 114: Ferrand E, Lemaire F, Regnier B, et al. Discrepancies between perceptions by physicians and nursing staff of intensive care unit end-of-life decisions. Am J Respir Crit Care Med 2003; 167: Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med 2003; 31: Puntillo KA, Benner P, Drought T, et al. End-of-life issues in intensive care units: a national random survey of nurses knowledge and beliefs. Am J Crit Care 2001; 10: Truog RD, Cist AF, Brackett SE, et al. Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 2001; 29: Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007; 356: Yaguchi A, Truog RD, Curtis JR, et al. International differences in end-of-life attitudes in the intensive care unit: results of a survey. Arch Intern Med 2005; 165: Parker PA, Kulik JA. Burnout, self- and supervisor-rated job performance, and absenteeism among nurses. J Behav Med 1995; 18: Weisman CS, Teitelbaum MA. Physician gender and the physician patient relationship: recent evidence and relevant questions. Soc Sci Med 1985; 20: McCue JD. The effects of stress on physicians and their medical practice. N Engl J Med 1982; 306: Vahey DC, Aiken LH, Sloane DM, et al. Nurse burnout and patient satisfaction. Med Care 2004; 42 (2 Suppl):II57 II Minvielle E, Dervaux B, Retbi A, et al. Culture, organization, and management in intensive care: construction and validation of a multidimensional questionnaire. J Crit Care 2005; 20: Taormina RJ, Law CM. Approaches to preventing burnout: the effects of personal stress management and organizational socialization. J Nurs Manag 2000; 8: McCue JD, Sachs CL. A stress management workshop improves residents coping skills. Arch Intern Med 1991; 151: Kluger MT, Townend K, Laidlaw T. Job satisfaction, stress and burnout in Australian specialist anaesthetists. Anaesthesia 2003; 58: Gopal R, Glasheen JJ, Miyoshi TJ, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med 2005; 165: Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351: Jenkins H, Allen C. The relationship between staff burnout/distress and interactions with residents in two residential homes for older people. Int J Geriatr Psychiatry 1998; 13: