As the nursing manager of a pediatric intensive care unit, you notice that one of your staff nurses has been more absent-minded and withdrawn recently. He’s an experienced nurse of 5 years and has always been personable, conscientious, and capable. However, recently he’s had a few near-miss medical errors, his sign-off communication to his colleagues has been subpar, and his interactions with family and patients lack their previous care and empathy. In a one-on-one discussion, the nurse reveals he is both mentally and physically exhausted, and the everyday physical and emotional stresses of working in a fast-paced intensive care unit with critically ill patients have started to affect his performance. Unfortunately, you recognize these sentiments all too well! Over the years, several highly competent nurses have resigned and left the organization because the demands of working in a high-intensity pediatric critical care unit left them feeling burned out.
Burnout syndrome is a high priority for all critical care nurse managers. Stressful work environments combined with the high cognitive load create additional challenges for nursing staff that affect workflow and direct patient care.1 Multiple studies have documented up to one-third of critical care nurses experiencing severe burnout syndrome and over 80% exhibiting at least one of the three classic symptoms (exhaustion, depersonalization, and reduced personal accomplishment).2-7 Furthermore, critical care nurses exhibit higher rates of burnout compared to other nursing disciplines.8 Burnout negatively affects the caregiver, patient care, and the hospital environment. Studies indicate that burnout is positively correlated with staff turnover,9 which may increase healthcare cost 10 and decrease productivity, unit morale, and overall quality of care.11
Many factors contribute to the development of staff burnout in the ED and ICU. In a study of 265 nurses, performance obstacles such as equipment-related issues were found to affect nurses’ perceptions of quality and safety of delivered care, as well as their quality of work life.12 In general, factors contributing to burnout may be categorized into personal characteristics, organizational factors, exposure to end-of-life issues, and quality of working relationships with other colleagues and providers.7
Among all of the stressful situations experienced by ED and ICU nurses, perhaps the most physically and mentally demanding is the resuscitation of hypotensive or cardiac arrest patients. In an evaluation of most common stressors among critical care nurses, unstable patients was ranked as most and moderately stressful in 24.4% and 47.4%, respectively.13 Early, rapid fluid resuscitation is foundational to the management of unstable patients. However, while many studies have evaluated the type, amount, and the expeditious use of fluids in the resuscitation of patients, little effort has been devoted to evaluating the impact of the method of fluid administration on stress. In a recent survey of nurses at the Emergency Nurses Association Annual Conference, nearly all nurses (52 of 53) agreed that a fluid bolus device that could reduce the complexity and stress in emergency situations would be very beneficial.
In a simulated fluid resuscitation study at Yale New Haven, LifeFlow®, a novel device for fluid resuscitation, was compared to two traditional fluid resuscitation methods: push-pull and pressure bag. The study simulated a standardized crystalloid infusion to a 10 kg patient in decompensated shock through a 22-gauge catheter.14 Twenty-seven teams of providers were randomly assigned to one of the resuscitation methods and instructed to provide three 20 ml/kg fluid boluses to a simulated infant based on vital signs and history. The primary outcome of the study was mean rate of fluid administration, which was fastest with LifeFlow (65.3 ml/min), followed by push-pull (46.2 ml/min), and lastly by pressure bag (42.2 ml/min), p<0.001. Workload was evaluated using the composite National Aeronautical and Space Administration Task Load Index (NASA-TLX). This tool measures the mental, physical, and temporal demands, as well as performance, effort, and frustrations associated with the task. Across all domains, LifeFlow was perceived to have a lower workload, evidenced by numerically lower NASA-TLX score in all categories. The composite NASA-TLX score was also significantly lower compared to pressure bag. Similarly, significant differences were observed in mental demands in favor of LifeFlow versus the other two methods.
Management of unstable critically ill patients is stressful. Empowering nurses with a more efficient and effective fluid resuscitation tool may help reduce stress and burnout, which is a win for nurses, nurse managers, and most importantly, patients.
- Wu P, Nam MY, Choi J, Kirlik A, Sha L, Berlin RB, Jr. Supporting Emergency Medical Care Teams with an Integrated Status Display Providing Real-Time Access to Medical Best Practices, Workflow Tracking, and Patient Data. J Med Syst. 2017;41:186.
- Embriaco N, Azoulay E, Barrau K, Kentish N, Pochard F, Loundou A, et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007;175:686-692.
- Mealer M, Burnham EL, Goode CJ, Rothbaum B, Moss M. The prevalence and impact of post traumatic stress disorder and burnout syndrome in nurses. Depress Anxiety. 2009;26:1118-1126.
- Mealer M, Jones J, Newman J, McFann KK, Rothbaum B, Moss M. The presence of resilience is associated with a healthier psychological profile in intensive care unit (ICU) nurses: results of a national survey. Int J Nurs Stud. 2012;49:292-299.
- Merlani P, Verdon M, Businger A, Domenighetti G, Pargger H, Ricou B, et al. Burnout in ICU caregivers: a multicenter study of factors associated to centers. Am J Respir Crit Care Med. 2011;184:1140-1146.
- Poncet MC, Toullic P, Papazian L, Kentish-Barnes N, Timsit JF, Pochard F, et al. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med. 2007;175:698-704.
- Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Healthcare Professionals: A Call for Action. Crit Care Med. 2016;44:1414-1421.
- Epp K. Burnout in critical care nurses: a literature review. Dynamics. 2012;23:25-31.
- Shoorideh FA, Ashktorab T, Yaghmaei F, Alavi Majd H. Relationship between ICU nurses’ moral distress with burnout and anticipated turnover. Nurs Ethics. 2015;22:64-76.
- Waldman JD, Kelly F, Arora S, Smith HL. The shocking cost of turnover in health care. Health Care Manage Rev. 2004;29:2-7.
- Ackerman AD. Retention of critical care staff. Crit Care Med. 1993;21:S394-395.
- Gurses AP, Carayon P, Wall M. Impact of performance obstacles on intensive care nurses’ workload, perceived quality and safety of care, and quality of working life. Health Serv Res. 2009;44:422-443.
- Hays MA, All AC, Mannahan C, Cuaderes E, Wallace D. Reported stressors and ways of coping utilized by intensive care unit nurses. Dimens Crit Care Nurs. 2006;25:185-193.
- Kline M, Crispino L, Bhatnagar A, Panchal RA, Auerbach M. A Randomized Single-Blinded Simulation-Based Trial of a Novel Method for Fluid Administration to a Septic Infant. Pediatr Emerg Care. 2018.