The central point of this study was that we assessed all critical care providers (physicians, nurses, nurse technicians and respiratory therapists) from both ICU and SDU to evaluate the prevalence of burnout syndrome and moral distress, and their association. The most important finding in our study was that moral distress was significantly associated with severe burnout. This study contributes to the growing body of evidence that burnout and moral distress are actually close phenomena.
In contrast to previous studies, in which the prevalence of severe burnout is of nearly 50% among critical care physicians [3] and one-third of critical care nurses [4], we found that physicians were the category that presented less burnout (18%) while nurses followed by respiratory therapists were the categories with the highest prevalence of burnout. One possible explanation for the low burnout prevalence among physicians compared with nurses may be due to the fact that physicians share the burden of decision making and care of patients in group and with the attending physicians. Another possible explanation is that the definition of burnout differs across studies. Although some studies have used the Poncet definition (MBI score > −9) [4], we chose to use a score according to the MBI manual high levels of emotional exhaustion and depersonalization combined with low scores on Personal Accomplishment) [16], which has also been done by other investigators [14, 19, 20]. In addition, the three-dimensional structure of the MBI is likely to provide more precise answers, leading to focused interventions.
Merlani et al., in a multicenter Swiss National study, found that nurse assistants (41%), followed by physicians (31%) and nurses (28%), had a high degree of burnout. Interestingly, the rate of a high degree of burnout among the ICU center ranged from 5 to 62%, with a mean of 28%, similar to our results (22.1% with severe burnout in the p-ICU) [21].
Moreover, the definition of burnout differs across studies. Although some studies have used the Poncet definition (MBI score > −9) [4, 21], we chose to use a score according to the MBI manual (high levels of emotional exhaustion and depersonalization combined with low scores on Personal Accomplishment) [16], which was also done by other investigators [14, 19, 20]. In addition, the three-dimensional structure of the MBI is likely to provide more precise answers, leading to focused interventions. This is the most common, widely described and internationally validated instrument used to assess all three dimensions of burnout [13].
In our study, whereas depersonalization was similar among all professionals, in accordance with previous studies, our study revealed that nurses presented high rates of emotional exhaustion and lower levels of personal accomplishment compared with other professionals [22]. Various studies have demonstrated that nursing is stressful and that the incidence of burnout in this profession is elevated due to their high demands, low resources, interprofessional conflicts, among other problems [14, 23, 24].
The present data differ from those of previous studies [2,3,4], in which determinants of severe burnout syndrome were associated with demographic characteristics, such as a high number of working hours and night shifts. Furthermore, we thoroughly sought to investigate many variables potentially involved in burnout, for instance, commuting distance, income, leisure time, family support and sexual activities, and we still were not able to find any demographic factor associated with severe burnout.
In addition, although we have interviewed the personnel of two units having distinct characteristics, we did not find any demographic significant difference according to the workplace. This similarity might be explained partially because both units care for severe, demanding patients and families, and the providers take care of a comparable number of critically chronic ill patients, who need a prolonged support. Further, both units have a rather open format of structural organization, which means that intensivists have to share with the attending physician important decisions regarding admission, discharge and withhold/withdraw of support.
Our findings demonstrate a significant, positive relationship between moral distress and burnout. Interestingly, we could observe that all providers scored similarly regarding moral distress, notwithstanding the highest degree of burnout in nurses. According to the literature, this association appears to be related to the performance of the nurse’s role as advocate of the patient. The nurse is usually identified as an essential source of many dilemmas, such as conflicts between legal and ethical obligations, perceived powerlessness, power distance, workload, perception of inadequate medical treatment and failed communication by the medical team [14, 25].
According to the regression analysis, moral distress was an independent predictor for severe burnout. It is possible that moral distress resulting from the moral atmosphere could lead to internal constraints such as self-doubt, lack of self-assurance, fear, anxiety and other situations that predispose to burnout.
It is noteworthy that items of moral distress such as situations in patients’ suffering, prolonging life, poor team communication, medical error and feeling of incompetence were associated with burnout. Almost 40 % of MDS-R questions that were associated with burnout were related to end-of-life decision making (see Table 3). Accordingly, it has been suggested that moral distress resulting from therapeutic obstinacy, that is, the implementation of potentially non-beneficial treatments, seems to have an important influence on the development of burnout [26,27,28].
Poncet et al. [4] identified severe burnout in one-third of ICU nursing staff and one of the domains associated with severe burnout were end-of-life-related factors, such as caring for a dying patient. It is important to point out that our results agree with those of other studies, showing that terminal care can be one of the most important drivers of burnout and moral distress [5, 8, 29,30,31,32].
Our study has some limitations. The most important is that conflicts were not assessed, since according to previous studies, higher burnout levels were significantly associated with the occurrence of conflicts [3, 13]. Furthermore, conflicts result mainly from disagreements about treatment, ethical decision making and end-of-life care and therefore were identified in literature as a major burnout risk factor [3, 13].
Second, the study was conducted in a single center, with unique characteristics. Third, a meaningful numbers of invitees who did not respond the MDS-R could have changed the results, had they answered. There is a chance that recall bias might have occurred, as those with burnout syndrome are more prone to recall events associated with moral distress. Fourth, selection bias might have played a role, as those who agreed to participate (and thus responded) did it exactly because they might have been suffering from burnout syndrome. Yet, the other way around might possibly be true: Those with burnout did not accept to participate. Finally, given the cross-sectional study design, we can only infer the causal relationship between burnout and moral distress syndromes.