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 Journal Sept. 13, 2015 http://www.edmontonjournal.com/nurses+lack+resources+ affecting+their+ability+properly+care+patients/11362077/st ory.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 posttraumatic stress
Major Root Causes of MDS 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. Hamric et al AJOB Prim Res 2012
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 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) 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
Relationship between Frequency and Intensity of Disturbance MDS scores largely attributed to intensity or level of disturbance with items rather than frequency Dodek et al JCRC 2015
Relationship between MDS Score and Response to Questions on Leaving the Workplace MDS scores correlated with tendency to leave ICU (both past and present) but was only statistically significant for nurses Dodek et al JCRC 2015
Healthcare Professional 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 MDS-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
Level of Disturbance (Median) 0 1 2 3 4 Level of Disturbance (Median) 0 1 2 3 4 Relationship between Frequency and Intensity of Disturbance a) b) 0 1 2 Frequency (Median) 3 4 0 1 2 Frequency (Median) 3 4 MDS scores again were shown to be more associated with intensity or level of disturbance with items rather than frequency Johnson-Coyle et al CJCCN 2016
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)
EXPECTIONS REALITY 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 problems Sleep disturbance Marital and relationship difficulties Rigid thinking Apathy Helplessness and hopelessness Muscular tension Self-righteousness Depression Vulnerability to illness Increased alcohol or drug use Over-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
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) Poncet 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 Embracio et al AJRCCM 2007
Personal Characteristics PTSD and Other Psychological Symptoms ICU Environment Moral Distress Perceived Delivery of Inappropriate Care Compassion Fatigue Burnout Syndrome Decreased Patient Satisfaction and Quality of Care Organizational Factors Increased Rates of Staff Leave and Attrition 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! Moss et al CCM 2016
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 Bakker et al J Adv Nurs 2005
Prevalence of Burnout 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Total RN/NP RRT Allied MD High Moderate Low 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
Moral Distress/Burnout - Emergent Themes 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 should be] better communication between surgical team and ICU team in regards to patient prognosis, plan and information provided to family and patient. [There should be] more frequent debriefing sessions [and an increased ability] to understand certain decisions being made by physicians in regards to patient care Bed Capacity Strain End-of- Life Care Themes Contributing to Moral Distress Complex Patients Team Communication Non- Beneficial Therapy 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]... [There should be] team discussion of [complex and] difficult cases I think sometimes we do wait to long to make a decision on end of life care. 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. Johnson-Coyle et al CJCCN 2016
Intervention Type Intervention Aim Example ICU organization Intensivist work schedule Improve workplace environment Change team composition Teambuilding and job rotation Weekend respite for intensivists* Shift work models* Comprehensive information + support program* Structure work shift evaluations* Person Practical Educational programs Educational seminars* Communication skills Relaxation exercises Mindfulness Intensive (EOLC focused) communication strategy Yoga* Facilitated discussion groups* Person Personal Personality and coping EI training* Social support and coping Counselling Facilitated peer support sessions
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 nonbeneficial 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
Thank You For Your Attention! bagshaw@ualberta.ca @drseanbagshaw