In 2016, the American Association of Critical Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine published a “Call to Action” in an effort to bring attention to the issue of burnout syndrome (BOS).1 Since then, numerous studies have shown that BOS is widely prevalent in almost all areas of healthcare.

Figure
figure 1

Themes causing burnout and moral distress

Full size image
Table Personal and workplace coping strategies
Full size table

Burnout is defined as a combination of emotional exhaustion, depersonalization, and a low sense of personal accomplishment.2 Burnout has significant implications for healthcare providers’, patients, and the organization. Literature indicates that healthcare professionals with BOS have higher rates of substance abuse, broken relationships, depression, post-traumatic stress disorder, and suicide.3,4,5 In the workplace, BOS has been tied to lower quality of patient care, increased patient dissatisfaction, increased medical errors, decreased productivity, poor team morale, and increased healthcare provider turnover. 6,7,8,9

Moral distress is believed to occur when individuals are placed in situations that are at odds with their core values and beliefs and that they have little power to change.10 Definitions in the literature often draw attention to key components such as complicity in wrongdoing, lack of voice, and wrongdoing associated with an organization’s professional values and practices.10,11,12,13,14 It is this pressure to act unethically that defines the phenomenon. A positive correlation between burnout and moral distress has been reported.15,16,17

Previous research quantified high rates of burnout and moral distress in the same ICU team.18 High and moderate levels of emotional exhaustion were 27.3% and 39.4%, respectively. Depersonalization was high in 13.9% and moderate in 33.3%. Low personal accomplishment was experienced by 27.9%, with a further 37.0% experiencing moderate personal accomplishment. 55.2% of participants reported moral distress at least a few times a month and 29.9% reported it at least once a week. Although the study used the Maslach Burnout Inventory,19 a well-validated measurement tool for BOS, it lacked in-depth exploration of possible contributors to burnout and moral distress in the team.

The purpose of this qualitative study was to explore in detail the factors, both at the individual and organizational level, that were contributing to burnout and moral distress in the healthcare team at the NSHA- Queen Elizabeth II Health Sciences Centre (QEII HSC) ICU, Halifax, Nova Scotia.

Methodology

Design and participant selection

Research Ethics Board approval was obtained in January 2019 (REB File #1024175). We used focus group methodology to elicit a qualitative stream of data to better understand issues related to BOS from a stakeholder-centred perspective as they react to and build on each other’s observations, perceptions, and thought processes.20 Participation was open to all registered intensive care nurses (RNs), respiratory therapists (RTs) and physicians working in the NSHA- Queen Elizabeth II Health Sciences Centre (QEII HSC) ICU. This ICU is closed and composed of two units; a 12-bed neuro-medical-surgical-trauma ICU with staff rotation through both sites. Staff were made aware of the study through departmental interprofessional presentations and study information displayed throughout the ICU. Focus group recruitment was by voluntary sign up on a first come, first serve basis until the focus groups were filled.

Written informed consent was obtained prior to the start of the focus groups. Study design consisted of six focus groups with four to eight participants per focus group. Given the ICU dynamics and psychologic safety of participants, groups were identified by professional designation. This included one physician group, one RT group, and four RN groups.

Focus group interview guide preparation

The focus group interview guide (eAppendix A in the Electronic Supplementary Material [ESM]) underwent iterative review and explored the daily work environment at both an organizational and individual level. It probed situations that contributed to burnout and moral distress, team dynamics, strategies currently used to cope with work stress, and interventions the participants thought helped build resilience. Standard definitions of burnout and moral distress were included in the interview guide and posted in the room during the focus group sessions (eAppendix B in the ESM). The facilitator of the focus groups was a university faculty member experienced in facilitating focus groups and was not connected to the ICU team.

Data analysis

A thematic analytic approach was used to guide analysis of the data.21 Thematic analysis is a six-part step-by-step technique to analyzing qualitative data that identifies themes and patterns, and generates rich description.

All focus groups were audiotaped; transcribed verbatim and field notes added contextual data. Qualitative software, Quirkos (www.quirkos.com), accommodated the storing, sorting, indexing, and coding of all data. Research team members independently read and reread each transcript and developed initial codes across the entire data set. Coding was largely an inductive or bottom-up activity. We compared the codes within the research team and resolved any differences through consensus. We then collected the codes according to potential themes. Themes were reviewed and a thematic analytic map was generated, followed by defining and naming the themes. Themes distilled were compared and contrasted between the key stakeholder groups. Finally, we produced a report and extracted compelling examples, and related our findings to the literature and research questions.

Results

Participant demographics

Thirty-five healthcare workers participated in total: six MDs, 21 RNs, and eight RTs. This represents 43% of the MDs, 18.8% of the RNs, and 20% of the RTs who work in the ICUs. The focus groups were primarily female (85.7%), with the exception of the physician group, which was predominately male (83.3%). All levels of work experience from junior to senior were well represented: 37.1% of participants had worked 0-5 years, 31.4% had worked 6-15 years, and 31.4% had worked 16+ years.

Burnout and moral distress

Although coding and thematic development were independent for both moral distress and burnout, three common themes emerged from both. The three overarching themes were organizational issues, exposure to high intensity situations, and poor team experiences, and these were further subdivided into subthemes (Figure). Quotes supporting each of the themes can be found in eTable 1 and eTable 2 in the ESM. Although these major themes emerged from all health professional groups, there was some variation in how they presented between groups.

Organizational subthemes included a lack of adequate physical resources, lack of adequate staffing, ineffective organizational policies, and disengaged administration. Decisions made by the health organization were often viewed to be at the expense of quality patient care or the physical and/or mental health of its employees. Within the organizational subthemes, there were some differences between health professions with respect to ineffective organizational policies. For example, in the physician focus group this included policies around bed management; however, nursing and respiratory therapy focus groups discussed policy inefficiencies regarding staff education.

Exposure to high intensity situations were described as contributing to both moral distress and burnout. The subthemes within this category included provision of futile care and end of life care, advocating for appropriate patient care, the healthcare provider-patient/family relationship, and workplace violence. While futile care, end of life care, and advocating for patient care were common to all professions, in this study, the complexity of patient and family relationships as well as workplace violence were unique to the nursing profession. Provision of futile care was the most frequently described situation causing both burnout and moral distress. Perceived futility of care was described as stemming from the medical team (any healthcare provider within the patient’s circle of care) and/or family who are not prepared to stop treatment. When the interdisciplinary team members have different beliefs on the level of treatment to be offered, it was reported to have a negative impact on both individual and team dynamics.

With respect to both burnout and moral distress, poor team experience subthemes included lack of control in the workplace, lack of appreciation by team members and administration, fragmented patient care, and negative team dynamics. Negative team dynamics comprised poor communication, lack of trust and respect, bullying, and lack of inclusion. Lack of inclusion in the team was unique to the respiratory therapy focus group and was only reported as a cause for burnout, not moral distress.

Significant overlap between the situations causing burnout and moral distress was noted. An example of this overlap is shown in the discussions regarding the need to advocate for appropriate patient care. In this example, clinicians described moral conflict when providing treatments they deemed to be outside of the patient’s stated wishes and feeling internal constraints to voice these concerns. Participants also described emotional exhaustion, a low sense of personal accomplishment, and detachment from the patient and families in these situations.

The impact of burnout and moral distress

Our data shows that the impact of working when facing burnout and moral distress is far reaching. Healthcare professionals reported a physical and emotional toll, impact on their family and home life, and a decrease in compassionate patient care. Many of these experiences elicited strong, negative emotional reactions such as anger, frustration, anxiety, fear, defeat, and demoralization in the healthcare provider (eTable 3 in the ESM). Often, these emotional experiences manifest themselves physically as overwhelming exhaustion. Along with the emotional toll, working in the ICU has a significant physical toll on the provider. Participants’ shared many stories about work-related injuries, physical exhaustion, and self-sacrifice.

The inability to leave work behind at the end of the shift was a common theme among nurses and RTs. This often had an impact on family dynamics; either in the form of isolation from loved ones or in the need for connection due to fear and anxiety of something bad happening. Universally, these experiences were felt to negatively impact the quality of delivered patient care in terms of loss of empathy and compassion. This in turn increased guilt experienced by the healthcare provider.

Coping strategies

Focus group participants were asked to provide examples of strategies for coping with workplace stressors both within and outside the workplace. Described strategies were both self-constructive and self-destructive. For example, excessive alcohol consumption is a self-destructive behaviour, while exercise is a self-constructive behaviour (Table).

Building resilience

Participants were asked to suggest interventions for building resilience. These suggestions are shown below and are organized by the three common themes identified as causing burnout and moral distress.

  • Organizational: improving staffing, investing in healthcare provider education, improving existing infrastructure, and adding new infrastructure.

  • Exposure to high intensity situations: regular debriefing sessions, destigmatizing the need for support, mental health wellness days, long-term follow-up on chronic patients that have left the ICU, addressing workplace violence.

  • Poor team experiences: inter- and intra-professional relationship building, teaching respectful communication and behaviours, acknowledgement of hard work and a job well done, supporting a just culture, hospital leadership engagement, and management support.

Discussion

In this study, three common themes emerged from the burnout and moral distress questions: 1) organizational issues, 2) exposure to high intensity situations, and 3) poor team experiences. In addition, an overlapping relationship was noted between situations that caused moral distress and burnout. The overlap between causes of burnout and moral distress is not unique to our study. In 2017, a survey of more than 200 ICU healthcare providers showed that moral distress, in particular due to provision of futile care, is significantly associated with the development of BOS.15 Similarly, two Canadian critical care studies also found an overlap in contributing factors.16,17

Prior studies have identified organizational issues like process inefficiencies, unbalanced workloads, and unsupportive organizational cultures/climates as a cause of burnout and moral distress. Organizational leadership has also been shown to have a significant impact on healthcare provider burnout, moral distress, and job satisfaction.22,23,24,25,26,27 Similar to sentiments expressed by our participants, a study of US healthcare professionals showed that much of the distress and dissatisfaction related to organizational issues came from the belief that these issues were negatively impacting quality patient care.28

Exposure to high intensity situations like end of life care and the provision of futile care were reported by all participants as a cause of burnout and moral distress, lending support to prior publications.6,15,25,29,30,31 Within our team, this impact came from the amount of exposure to death and dying, as well as situations in which there were discrepant expectations in escalation of care. Discrepant expectations were reported not only between the team and a patient’s family or surrogate decision maker but also within the team as well. These differences in care plans have been previously described as a source of moral distress, workplace dissatisfaction, and burnout,16,29,30,31,32,33,34 further emphasizing the need for communication and relationship building when considering strategies to build resilience.

A consistent theme throughout all focus groups was the magnitude of exposure to tragedy and grief in the ICU. Many participants described feeling isolated as family and friends are not able to comprehend a typical workday and the need for regular formal debriefing sessions was advocated for. Studies on the impact of debriefing interventions on psychologic well-being are mixed. Similar to our results, the request for debriefing sessions and greater psychologic support has been identified in other studies of intensive care health professionals.35,36 Although there were no objective measures of psychologic impact, two studies reported that attending debriefing sessions and talking with colleagues were independently associated with a reduced risk of burnout and enhanced resilience.37,38 In 2018, Browning illustrated a decrease in moral distress in ICU nurses when debriefing sessions were provided on a regular basis over a six month interval. At the end of the study period, 100% of participants requested that sessions continue.39 Conversely, a 2018 meta-analysis of ten studies exploring the effects of post-disaster psychologic interventions included three studies that suggested debriefings can have long-term positive effects with respect to depression, anxiety, substance abuse and PTSD,40,41,42 and seven studies that showed no difference.43

Many important subthemes emerged in relation to poor team experiences contributing to burnout and moral distress; the largest contributor was negative team dynamics in the form of hostility in the workplace, toxic personalities, lack of inclusion in the team environment, lack of respect, poor communication, as well as shaming and bullying. A recent review by Smith et al. described effective teamwork as needing several key features, including: 1) psychologic safety: the team members’ ability to trust one another and feel safe enough within the team to admit a mistake, ask a question, offer new data, or try a new skill without fear of embarrassment or punishment and 2) the ability for team members to learn, teach, communicate, reason, think together, and achieve shared goals, irrespective of their individual positions or status outside the team.44 Psychologic safety was particularly relevant to our focus groups participants as they often expressed a desire for their experiences of shame and fear related to errors to be replaced by a philosophy of just culture within the organization. Research into negative team dynamics has shown a significant impact on job satisfaction, burnout, and moral distress.11,25,45,46 Equally important, the reverse also holds true. Positive team interactions can help improve workplace satisfaction, mitigate burnout, and build resilience.45,47,48,49,50 This suggests that investing in strategies to improve team dynamics would be a useful way for the organization and ICU leadership to build resilience among their workers.

Lack of appreciation was a common theme for all focus groups and was felt from all levels of hospital administration. The form of appreciation desired was often simple, such as an in-person thank-you or acknowledgements of positive achievements. Similar experiences are described in the literature as contributing to burnout in the healthcare team, while attending to these deficiencies helps alleviate stress and build resilience.16,24

This study affirmed previous data that burnout and moral distress are significant issues within this ICU team,18 and taught us about the root causes through exploring everyday work. Strengthening our thematic analysis, the research group consisted of a multidisciplinary team, reducing bias in the interpretation of results. Our results are also strengthened by numerous other publications that have reported similar causes for workplace burnout and moral distress. There may have been confirmation bias in the focus group members, which may have led to an overestimation of the problem. Nevertheless, based on our previous ICU study that had a high percentage participation, we do not think that this is a relevant problem.18 Another potential weakness is that participants may not represent the opinion of the majority of the ICU team as the focus group enrollment was self-selected. Since many of the themes were similar across different professional groups, we do not feel this to be the case. Instead, it gives our study internal validity. Finally, it should also be acknowledged that differences between the groups may not reflect true differences, but may reflect the organic nature of focus group conversations. The facilitator was provided with a guide of key questions, not questions pertaining to specific interventions or problems.

Conclusions

Findings in the data were consistent. Working in an environment of burnout and low morale impacts the physical and mental health of healthcare providers, their relationships with friends and families, and the care of patients. There were many worthy suggestions identified by participants for building resilience in the three domains that contribute to burnout and moral distress, some of which are supported by the literature. Some examples include debriefing sessions, long-term follow-up on ICU patients with positive outcomes, fostering a positive team environment that is supportive and collegial, and encouraging re-engagement of hospital leadership. Implementation and evaluation of the impact of these interventions will be the basis of future work.