American Thoracic Society
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                  What is Burnout Syndrome (BOS)?
                     First described in the 1970s, BOS is a work-related constellation 
                     of symptoms that usually occurs in individuals without any 
                     prior history of psychological or psychiatric disorders. BOS 
                     is triggered by a discrepancy between the expectations and 
                     ideals of the employee and the actual requirements of their 
                     position. In the initial stages of BOS, individuals feel emotional 
                     stress and increasing job-related disillusionment.
                  Subsequently, they lose the ability to adapt to the work               symptoms of severe BOS, and up to 86% have at least one of 
                  environment and display negative attitudes toward their job,           the three classic symptoms. When compared to other types of 
                  their co-workers, and their patients. Ultimately, three classic        nurses, BOS occurs more commonly in critical care nurses. BOS 
                  BOS symptoms develop: exhaustion, depersonalization, and               is also common in critical care physicians. Up to 45% of critical 
                  reduced personal accomplishment.                                       care physicians reported symptoms of severe BOS. Among 
                  1. Exhaustion: is generalized fatigue that can be related to           pediatric critical care physicians the prevalence of BOS is 71%, 
                  devoting excessive time and effort to a task or project that is not    more than twice the rate in general pediatricians. 
                  perceived to be beneficial. For example, a feeling of exhaustion,      How to Measure and Detect BOS
                  particularly emotional exhaustion, may be caused by continuing         Burnout syndrome is most commonly measured with the 
          PY      to care for a patient who has a very poor chance of recovery.          Maslach Burnout Inventory (MBI-HS). The MBI-HS is a 22-item 
          CO      2. Depersonalization: is a distant or indifferent attitude             self-report questionnaire that consists of three independently 
                  towards work. Depersonalization manifests as negative, callous,        scored dimensions (emotional exhaustion, depersonalization and 
           AND    and cynical behaviors; or interacting with colleagues or patients      a lack of personal accomplishment). The questions on the MBI-
                  in an impersonal manner. Depersonalization may be expressed            HS classify feelings related to an individual’s work environment 
          CLIP    as unprofessional comments directed toward co-workers,                 on a 7-point Likert scale. The emotional exhaustion scale includes 
                  blaming patients for their medical problems, or the inability to       9 items and identifies individuals who are emotionally exhausted 
                  express empathy or grief when a patient dies.                          or who feel overextended at work, the depersonalization scale 
                  3. Reduced personal accomplishment is the tendency to                  includes 5 items and identifies those who have an impersonal 
                  negatively evaluate the worth of one’s work, feeling insufficient      response to patients they are taking care of and the personal 
                  in regard to the ability to perform one’s job, and a generalized       accomplishment scale includes 8 items and assesses a lack of 
                  poor professional self-esteem.                                         accomplishment and success related to work.
                  Individuals with BOS may also develop non-specific symptoms            Risk factors
                  including feeling frustrated, angry, fearful, or anxious. They         Both individual and organizational risk factors are associated 
                  may also express an inability to feel happiness, joy, pleasure,        with an increased susceptibility to develop BOS.
                  or contentment. BOS can be associated with physical                     Individual risk factors:            Organizational risk factors: 
                  symptoms including insomnia, muscle tension, headaches, and             • having poor self-esteem           • heavy workload
                  gastrointestinal problems.
                  Magnitude of the Problem                                                • maladaptive coping mechanisms • conflicts with coworkers
                  Healthcare professionals at the front line of care (family              • younger adults with an            • diminished resources
                  medicine, emergency medicine, general internal medicine,                  idealistic worldview              • lack of control or input
                  and critical care) report the highest rates of BOS; in excess           • unrealistically high              • effort-reward imbalance
                  of 40%. Working in an Intensive Care Unit (ICU) can be                    expectations                      • understaffing
                  especially stressful due to high patient morbidity and mortality,       • having financial issues           • rapid institutional changes
                  challenging daily work routines, and routine encounters with            Specific to the critical care environment, risk factors for nurses:
                  traumatic and ethical issues. This level of nearly continuous           • variability in work schedules
                  stress can rapidly accelerate when caregivers perceive that             • rapid turnover of patients
                  there is insufficient time or limited resources to properly care for    • end-of-life events
                  patients. Unfortunately, critical care healthcare professionals 
                  have one of the highest rates of BOS. Based upon multiple              Critical care physicians share many of the same risk factors as 
                  studies, approximately 25-33% of critical care nurses manifest         nurses but struggle most with the amount of uninterrupted 
                                                                                                                 Am J Respir Crit Care Med Vol. 194, P1-P2, 2016
                                                                                          ATS Public Health Information Series © 2016 American Thoracic Society
                                                                                                                                      www.thoracic.org
                                                                                                                                                                                                                    American Thoracic Society
                                                                                                                                                                 PUBLIC HEALTH | INFORMATION SERIES
                     work they are expected to complete (weekend and night                                                                                     prevent and treat BOS. The six standards include: 
                     coverage).                                                                                                                                    • having skilled communication                                           • appropriate staffing
                     Consequences of Burnout Syndrome                                                                                                            • collaboration                                                            • meaningful recognition
                     BOS in critical care healthcare professionals may result in                                                                                   • effective decision-making                                              • authentic leadership
                     post-traumatic stress disorder (PTSD), alcohol abuse, and even                                                                            A small randomized controlled trial of resilience training 
                     suicidal ideation. PTSD is manifest by intrusion, avoidance,                                                                              was conducted in ICU nurses. Validated surveys were used 
                     negative alterations in cognition and mood, and marked                                                                                    to measure resilience, PTSD, anxiety, depression and 
                     alterations in arousal and reactivity. PTSD can occur in response                                                                         burnout syndrome. The intervention arm included a two-day 
                     to one catastrophic event or after chronic or repetitive exposure                                                                         educational workshop, written exposure therapy, mindfulness-
                     to traumatic episodes. Between 22-29% of critical care nurses                                                                             based stress reduction (MBSR), exercise and event triggered 
                     have symptoms of PTSD, and up to 18% of critical care nurses                                                                              cognitive behavioral therapy sessions. The control arm did not 
                     meet the diagnostic criteria for PTSD.                                                                                                    have any interventions dictated by the protocol. The results 
                     The development of BOS may result in healthcare professionals                                                                             suggested the intervention was feasible and acceptable. There 
                     leaving their profession. Excessive turnover rates increase                                                                               was also improvement in resilience scores, PTSD symptom 
                     healthcare costs, decrease productivity, diminish staff                                                                                   scores and symptoms of depression. Larger randomized 
                     morale, and reduce the overall quality of care as experienced                                                                             controlled trials are needed that are powered to reach 
                     professionals who leave the ICU must be replaced. In ICU                                                                                  statistical significance. 
                     nurses, turnover occurs frequently with reported annual rates                                                                              Additional research is needed to identify strategies and 
                     ranging between 13-20%: the 2013 U.S. average annual turnover                                                                             interventions that prevent and treat burnout syndrome 
                     rate for all types of employees was 10.4%.                                                                                                and other psychological disorders such as PTSD, anxiety 
                     BOS also results in decreased clinical effectiveness and poor                                                                             and depression in pulmonary and critical care healthcare 
                     work performance that may impact patient care. BOS in                                                                                     professionals.
                                                                                                                                                               Authors: Meredith Mealer, PhD, Marc Moss, MD.,Vicki Good, 
                                                   Cost of replacing an                                                                                        RN, MSN, CENP, CPPS, David Gozal, MD, MBA, Ruth Kleinpell, 
                                                   ICU nurse is > $65,000                                                                                      PhD RN FAAN FCCM, Curtis Sessler, MD, FCCP, FCCM  
                                                                                                                                                               Reviewers: Marianna Sockrider, MD, DrPH, Christopher Slatore, 
                                                                                                                                                               MD, MS
                                                                           Cost of replacing an                                                                    R Action Steps
                                                                           ICU physician > $250,000
                                                                                                                                                                  1. Understand that there are ways you can manage your work-
                                                                                                                                                                      related stressors that put you at risk for burnout syndrome.
                     nurses is associated with lower quality of care, lower patient                                                                               2. Engage the support of management, co-workers and friends 
                     satisfaction, increased number of medical errors, increased                                                                                      that may help you cope with stress at work and burnout 
                     rates of health-care associated infections, and higher 30-day                                                                                    syndrome.
                     mortality rates. There is a strong “dose-response” and “bi-                                                                                  3. Take breaks from work. Go outside for a walk or fresh air. 
                     directional” relationship between burnout scores and medical                                                                                     Exercise is known to enhance your physical state and mood.
                     errors: errors lead to distress and distress leads to errors                                                                                 4. Understand what you enjoy about work and focus on your 
                                                                                                                                                                      interests and passions. 
                     Potential Treatment or Prevention for BOS                                                                                                    5. Practice techniques such as reframing and optimism when 
                     Evidence-based interventions to treat and prevent BOS are                                                                                        dealing with stressful work experiences.
                     currently not available in critical care healthcare professionals. 
                     Interventions focused on both the individual and organizational                                                                               Additional Resources
                     interventions should be developed. Resilience is a psychological 
                     characteristic that enables an individual to adjust in a healthy                                                                              Maslach, C., Schaufeli, W. & Leiter, M. (2001). Job Burnout. Annual 
                     way after a traumatic event. Resilience has been recognized as                                                                                Review of Psychology, 397-422.
                     a mechanism to mitigate symptoms of and the development                                                                                       Mealer, M. et al. (2014). Feasibility and acceptability of a resilience 
                     of PTSD following trauma and may prevent and treat of BOS.                                                                                    training program for intensive care unit nurses. American Journal of 
                     While there are innate or inherent qualities of resilience, there                                                                             Critical Care, 23(6), 97-105.
                     are qualities of resilience that can be learned. Examples of                                                                                  American Association of Critical Care Nurses 
                     resiliency techniques include: being optimistic, developing                                                                                   www.aacn.org
                     cognitive flexibility, establishing and maintaining a supportive                                                                              Maslach Burnout Inventory (MBI)—abbreviated version, available at
                     social network, mindfulness training, and exercising.                                                                                         https://www.aap.org/en-us/Documents/soim_abbreviated_maslach_
                     Organizational interventions should be aimed at sustaining a                                                                                  burnout_inventory.pdf 
                     healthy work environment. The American Association of Critical                                                                            This information is a public service of the American Thoracic Society.  
                     Care Nurses (AACN) has identified six standards to establish and                                                                          The content is for educational purposes only. It should not be used as a 
                     sustain a healthy work environment that could be targeted to                                                                              substitute for the medical advice of one’s health care provider.
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