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1Running Head: BURNOUT IN CRITICAL CARE NURSES

Exploring Critical Care Nurses' Perceptions of their Burnout and Insight for Change

Tami R. E. McKenzie

Athabasca University

MHST/NURS603 – 2019

Assignment #3: Research Proposal – Literature Review and Methods

2BURNOUT IN CRITICAL CARE NURSES

Abstract

Burnout is especially common in health care professionals who provide care to critically ill

patients (Moss, Good, Gozal, Kleinpell & Sessler, 2016). Approximately twenty-five to thirty-

three percent of critical care nurses experience symptoms of burnout. A low incidence of burnout

would require nurses reporting that they experienced burnout symptoms a few times a year, yet

Intensive Care Unit (ICU) nurses at Hamilton Health Sciences (HHS) stated that they

experienced these symptoms a few times a month (Oczkowski, 2018). Exploring these nurses’

perceptions of the contributors to their burnout and insight for change, can delineate a

multidimensional approach to burnout management in the critical care setting. The purpose of

the proposed phenomenological study is to clarify the components that are necessary to cultivate

this foundation. Important to this study, is the acknowledgment and inclusion of the condition,

moral distress, as it is intimately related to burnout (Dzeng & Curtis, 2018). The results from this

study could leverage a sustainable foundation of resilience and support for critical care nurses.

Keywords: burnout, critical care, ICU, nursing, resiliency, moral distress


Exploring Critical Care Nurses' Perceptions of their Burnout and Insight for Change

Maslach and Jackson (1981) originally described burnout in the helping profession as a

psychological syndrome that results from prolonged job strain. Burnout occurs when the

expectations and ideals of the employee do not align with the actual requirements of the job

(Maslach & Leiter, 1997). Leiter and Maslach (2004) state that burnout is a disconnect between

an employee and their work environment. Critical care nurses are susceptible to burnout due to

the chronic occupational stressors to which they are exposed, such as high patient acuity and

responsibility, balancing care of the patient with care of the family in shock, and the moral

distress associated with providing futile treatment at end of life (Epp, 2012).

As high as 86% of critical care nurses suffer from at least one of the classic symptoms of

burnout (Moss et al., 2016). In 2018, critical care nurses working in three ICUs at HHS, filled

out the Maslach Burnout Inventory (MBI), which indicated that 86% and 95% of nurses

experienced the first and second symptom of burnout, respectively (Oczkowski, 2018).

Regrettably, when nurses suffer in this way, they can be seen as failing or vulnerable (AMS

Healthcare, 2019; Pauly, Varcoe, Storch & Newton, 2009). This can create a culture of blame

and shame and place too much emphasis on self-care (AMS Healthcare, 2019). Workplace

interventions should extend the focus from the individual to include organizational factors,

acknowledging that the health of nurses is intrinsically connected to their work environment

(AMS Healthcare, 2019; Bragadottir, 2016). Advocating for practice settings with less stress and

burnout, will result in lower nurse turnover, higher retention, and better patient outcomes (Aiken

et al., 2012; Bragadottir, 2016; Chlan, 2013). A multidimensional approach is needed to combat

this complex problem and to establish a foundation of resilience and support (Moss et al., 2016;

AMS Healthcare, 2019). Exploring critical care nurses’ perceptions of the contributors to their


burnout and their insight for change, can help define a multidimensional approach to burnout

management for nurses.

Definition of Burnout

Burnout consists of three symptoms (Moss et al., 2016). Emotional exhaustion is the

generalized fatigue that results from devoting time and energy to something that is not perceived

as being beneficial. It is the central symptom of burnout and it prompts the need to distance

oneself from one’s work (Maslach, Schaufeli & Leiter, 2001). Depersonalization occurs as a

consequence to emotional exhaustion and is this self-protective response to put distance between

one’s work demands and oneself (Leiter & Maslach, 2004). It refers to a detached and cynical

approach to work, interacting in an impersonal or dehumanized way. Finally, reduced personal

accomplishment refers to negatively viewing the value of one’s work (Moss et al., 2016).

Literature Review

A literature review was performed to examine the current state of research in burnout

management for critical care nurses. A search was conducted in CINAHL, PubMed and the

Cochrane Library, yielding 130, 84 and 12 articles, of which 12, 2 and 1 were relevant for this

review, respectively. A combination of subject headings was used, including burnout, resilien*,

moral distress, secondary traumatic stress, vicarious trauma, critical care nurs*, perception, nurse

attitudes, multidimension*, multifacet*, interview, and qualitative. The articles selected for this

review pertain to critical care nursing, and discuss burnout in terms of its contributors, nurse

coping, or its multidimensional management. Articles were excluded when they were redundant

to the previously included articles, in terms of understanding current burnout research.

Moral distress has a strong presence in the literature in terms of its contribution to

burnout. A theme noted in the literature is how nurses cope with their workplace stressors, and


this research supports the theory that guides this study. Although limited, the literature also

discusses multidimensional approaches to managing burnout.

Moral Distress

Moral distress occurs when an individual knows the ethical action to take but is prevented

from doing so (Sauerland, Marotta, Peinemann, Berndt & Robichaux, 2014). Physicians may

experience less moral distress because they are responsible for the decision-making (Chlan,

2013; Epp, 2012; Mealer & Moss, 2016; Moss et al., 2016). Nurses report being frustrated with

their ability to facilitate end-of-life care because physicians are dishonest in their communication

of patients’ prognoses (Badger, 2005; Forozeiya, Vanderspank-Wright, Fothergill Bourbonnais,

Moreau & Kenneth Wright, 2019). Browning & Cruz (2108) state that when ICU nurses

advocated for a truthful prognosis, they felt empowered, suggesting that interprofessional

collaboration may protect nurses from burnout. This link between interprofessional collaboration

and burnout is supported elsewhere in the literature (Epp, 2012; Schwarzkopf et al., 2017).

Moral distress has been identified as a key contributor to burnout (Browning & Cruz,

2018; Chlan, 2013; Epp, 2012). The most distressing facet of nurses’ moral distress is providing

nonbeneficial care to patients. Meltzer and Huckabay (2004) showed that moral distress was

directly and significantly related to the burnout dimension, emotional exhaustion, particularly

when providing futile care. Futile care is defined as life-sustaining interventions that would not

prevent a dependency on ICU-level care. Similarly, Schwarzkopf et al (2017) found that

perceived nonbeneficial treatment of patients was associated with emotional exhaustion, but that

emotional exhaustion also mediated the effect of nurses’ intention to leave their jobs. In the

context of the Six Areas of Worklife model, nonbeneficial treatment may represent a value

mismatch between the individual and the critical care setting (Schwarzkopf et al., 2017).


How Critical Care Nurses Cope with Their Workplace Adversity

Seeking supportive relationships with coworkers is described frequently as a technique

that critical care nurses use to cope with workplace struggles (Branco, 2017; Forozeiya et al.,

2019; Jackson et al., 2018; Kuza, 2018; Mason et al., 2014; Pelletier-Hibbert, 1998). The most

frequently cited reason for nurses seeking out other nurses in their time of need, is their

contextual understanding of a situation (Badger, 2005; Forozeiya, 2019; Jackson et al., 2018)

Nurses’ awareness of how adversity is affecting them is emphasized in the literature. In

addition to being Jackson et al’s (2018) driver in their process of managing exposure, awareness

was noted by Branco (2017), when she found that critical care nurses were able to recognize the

toll that moral distress was taking on them and decide on the proactive approach to confront

conflicts. Forozeiya et al (2019) refers to nurses turning towards their moral distress when they

connected with their feelings. Interestingly, emotional intelligence, being aware of one’s

emotions, regulating them and using them to steer one’s thinking and actions, is becoming more

abundant in the literature as it pertains to managing moral distress in critical care (Lewis, 2019).

This ability to exercise control over one’s emotions, has been described as a coping strategy

when caring for organ donors and their families (Pelletier-Hibbert, 1998). This is especially true

during the emotional initial phase of the process where the decision has not yet been made by the

family to proceed with organ donation. Moving through such adversity leads to meaningfully

engagement at work (Forozeiya et al., 2019; Jackson et al., 2018). Depending on the extent of

their engagement, the nurse could be described as thriving or resilient (Jackson et al., 2018).

Alternatively, critical care nurses can use avoidance and distancing techniques to cope

with critical care work, as well as enforcing a separation between home and work life (Badger,

2005; Forozeiya et al., 2019; Jackson et al., 2018; Mason et al., 2014; Pelletier-Hibbert, 1998).


Evidence of a Multidimensional Approach to Burnout

Moss et al (2016) recognizes that it is unlikely that a single intervention will be

successful in managing burnout in critical care, but rather a multidimensional approach is

needed. Recommendations from their review of the literature are included under each of the

following categories: 1) environmental interventions; 2) factors that promote a healthy work

environment; 3) team-based interventions; 4) practitioner-focused interventions; and 5)

interventions to mitigate risk factors (See Appendix B). Foglia & Grassley (2010) showed that

multidimensional environmental characteristics contributed to ICU nurses’ unrelieved job stress

and their decision to leave their position (see Appendix C). While burnout is not mentioned in

this conceptual model, some nurses reported that their unrelieved job stress resulted in burnout.

Contributors to this stress were: caring for families, the high acuity and skill set required,

inexperienced nurses, staffing, inadequate time for grieving, and negative perceptions of leaders.

Gaps in the Literature

Dzeng & Curtis (2018) state that there is a need to “look for systemic and cultural root

causes of burnout”, such as moral distress (p. 768). The literature points to recommendations that

can alleviate burnout and highlights the significant role that moral distress plays in this

phenomenon, but a unified approach remains unclear. Mealer, Hodapp, Dimidjian, Rothbaum &

Moss (2017) state that a resilience program that targets burnout first requires an understanding of

the contributors relevant to the local ICU environment. Further research to understand the

contributors to burnout, including moral distress, that takes into account the unique needs of

critical care settings, will help inspire a definitive foundation for managing this phenomenon.


Statement of Purpose

It is not known how to outline a burnout management plan for critical care nurses, that

combines root causes of burnout with strategies for change. This phenomenological study seeks

to uncover this multidimensional approach, using phenomenology as the study design.

Research Questions

The following research questions are presented:

1. What are the lived experiences of critical care nurses who suffer from burnout?

2. Can ICU nurses offer insight into their needs that can collectively contribute to a

multidimensional approach to burnout management?

Methods

Theoretical Framework

A model and a theory will be used to guide this study’s data collection and analysis. They

were chosen specifically for their ability to explain the progression to burnout and the key areas

that can influence burnout.

Rationale for Model

Maslach and Leiter’s (1997) Six Areas of Worklife model states that burnout occurs

when there is a chronic mismatch between people and their work environment, in some or all of

the following areas: workload, control, reward, community, fairness and values. Thus, the focus

of this model is establishing a sustainable working relationship between people and their

organization (Leiter and Maslach, 1999). All six of these areas were shown to be significantly

associated with burnout (Leiter & Maslach, 2004). Workload refers to the time and resources that

an employee has to meet work demands; control is the autonomy one has over their work;

rewards is the recognition of contributions; community is the quality of working relationships;


fairness is the extent that input is respected and welcomed; and finally, values refers to the

compatibility of the employee’s values with that of their employer’s. Leiter & Maslach (1999)

encourage research that assesses all six areas of worklife together, as doing so in isolation,

restricts the understanding of the complex interrelationships among these domains.

The rationale for including this model is that it offers structure to a multidimensional

approach to burnout management that is rooted in burnout research. If nurses in this study

mention staffing as a contributor to burnout for them, and the staffing model is proposed by them

as an area to be redeveloped, this need would be categorized as workload. This workload

strategy, along with the other identified strategies that fall within the six areas of worklife, would

then become the blueprint for burnout management for these nurses.

Rationale for Theory

Workplace adversity is defined as any negative situation or hardship encountered in the

work environment (Jackson, Firtko & Edenborough, 2007). Jackson, Vandall-Walker,

Vanderspank-Wright, Wishart & Moore’s (2018) theory, Managing Exposure: Resilience and

Burnout in Critical Care Nurses, describes the process that critical care nurses go through when

faced with workplace adversity (see Appendix A). Awareness is the driver of this process

because without awareness of the impact that adversity is having on them, nurses cannot take

action to support themselves (Jackson et al., 2018). The nurse then employs a technique in an

attempt to manage adversity. These techniques include: 1) protecting (disengaging,

depersonalization, and humour); 2) processing (reflecting with colleagues); 3) decontaminating

(engaging in meaningful activities outside of work and seeking supportive relationships both at

home and at work); and 4) distancing (physically removing oneself from the bedside or the unit).

Depending on the nurse’s success in being able to manage their exposure to adversity with their


technique, they will self-identify with one of four indicators, along a continuum. On one end,

nurses are considered to be thriving, when they are fully engaged in critical care, and, resilient,

when they are still engaged, but less so. Resilience is defined as the ability to overcome adversity

and move forward in a positive way (Jackson et al., 2007). It has been described as both a

characteristic of the individual and the workplace (AMS Healthcare, 2019). On the other end of

the continuum, is survival, meaning that nurses are managing their exposure to adversity at a

suboptimal level, and, burnout where nurses are not able to adequately manage their exposure

(Jackson et al., 2018). Nurses can experience different indicators at different points in their

careers and even from one shift to the next.

The rationale for choosing this theory to guide this study, is that it explains nurses’

behaviours when faced with adversity at work. It gives clarity into the extent that nurses engage

or disengage when their workplace may not be supporting them. For example, nurses in this

study may indicate that they seek out one another in moments of hardship. Relating this theory to

the Six Areas of Worklife model, if a debrief with colleagues after a critical event is identified by

these nurses to be essential to preventing burnout, this would be categorized as community.

Participants

Full and regular part time Registered Nurses (RN) working at HHS in ICU East/South

and ICU West at the HGH, and the JH ICU, will be recruited for this study. ICU East and South

will be grouped as a single location, since the same nurses staff these units, and they are identical

in terms of their functioning. With the phenomenological approach, no criteria are placed on who

can be a participant, other than their having lived the experience being studied (Macnee, 2004).

Therefore, there are no requirements for age, gender, level of education, or ethnicity. However,

to account for the new staff, it is a requirement to have been employed for at least one year.


Procedures

Sampling Strategy.

Purposive sampling involves seeking out particular individuals because of their

experience with the phenomenon of interest (Macnee, 2004). Due to the severe burnout scores

from the JH and HGH ICUs the year prior, the participants will be selected from these units. It

cannot be a requirement that only the nurses that filled out the survey in 2018 make up the

sample because the MBI was filled out anonymously. This sampling strategy was also one of

convenience, as the sampling frame includes nurses from the workplaces of the researchers.

Following REB approval, two administrators from the JH and HGH ICUs will use unit

distribution lists to invite nurses to participate in this study. A flyer will accompany the email

(see Appendix D). Prospective participants will be able to ask questions to further their

understanding of the study’s purpose, by replying to the email. Administrators will anonymously

direct questions to one of the researchers. They will keep participant selection confidential by

assigning participants a unique number. Other than sending the original email, redirecting

questions, and booking interviews and follow up interviews, the administrators will have no

further involvement in the study. Every effort will be made to encourage participation from all

three ICUs, with the understanding that ICU West does have a smaller nursing staff.

Sample Size

The number of participants needed for a rich portrayal of the phenomenon is not defined

before implementation of a phenomenological study, as data collection continues until data

saturation is achieved (Macnee, 2004). Thus, no estimate of sample size has been calculated.


Design

A phenomenological design is proposed for this study. Phenomenology is used to

understand a phenomenon as perceived by those who experience it (Macnee, 2004). The MBI

from 2018 allowed for the quantitative analysis of the state of burnout in three of HHS’ ICUs.

Taking a phenomenological approach, will allow for an understanding of the deeper meaning of

the complicated picture of burnout for these nurses.

In phenomenology, the lived experience of participants is often realized through

unstructured interviews (Macnee, 2004). Skilled interviewing is essential for the richest sharing

of experiences (Bhattacherjee, 2012). Since interviewing is a new skill for both researchers, they

will first be trained, and conduct practice interviews in an ICU outside of HHS. To maintain the

integrity of the study, since one of the researchers is employed as an RN at the JH ICU and the

other, an RN at the HGH ICU, the researchers will conduct interviews with staff at the hospital at

which they are not employed. Due to their current employment at HHS, and the fact that both

researchers filled out the MBI in 2018, which may have indicated that they themselves are

suffering from burnout, they may have personal biases. Bracketing is a strategy to manage

personal biases and strengthens the confirmability of a study’s results (Cypress, 2017). At the

onset of the study, the researchers will discuss their biases with colleagues, and throughout the

study, they will both keep careful journals documenting their thoughts and feelings with respect

to their own biases. These notes will be shared in the final research report.

At the start of each interview, the researchers will review the informed consent document

with the participants and obtain their signature if they are in agreement with the terms of the

document. It will be emphasized that participants can remove themselves from the interview at

any time and reiterated that their responses will be kept strictly confidential. Interviews will be


audiotaped. Face-to-face, semi-structured interviews will be conducted in a meeting room

outside of the ICU, that is predetermined to be both comfortable and spacious. The opening

question will be, “can you describe a situation that best represents the burnout that you are

experiencing in the ICU?”. Three secondary questions will be asked: “can you identify needs that

were unmet in your scenario?”, “can you propose potential strategies to address the needs that

you described?” and, “can you explain how you were able to cope in your scenario?”. Probing

questions will be asked, only when clarification or elaboration of statements is needed. Moral

distress will be left out of direct questioning; this was deliberate, to allow for the organic sharing

of this contributor to the participants’ burnout. They will be asked to describe two scenarios in

total. Careful field notes will be kept by each researcher, noting facial expressions, body

language, and emotional responses. These notes contribute to an audit trail that will include

decisions made during data collection and analysis (Macnee, 2004). An audit trail strengthens the

confirmability of the results (Cypress, 2017). Data collection will continue until data saturation is

achieved.

Planned Data Analysis

With any qualitative approach to research, data collection and analysis occurs

simultaneously (Bhattacherjee, 2012). This means that the data can be coded before progressing

to the next interview, while also allowing for tweaking of the interview protocol. In this study,

the researchers will code each participant’s need according to Maslach and Leiter’s (1997) Six

Areas of Worklife model. If there is disagreement in coding a particular need, the researchers

will collaborate. If no decision is made, this will be noted in the final report. Once a need is

coded for the first time, it will consistently be coded the same way.


After the interviews are transcribed, the researchers will listen to the audiotapes to verify

the accuracy of the collected data. The transcribed data and the audiotapes will be securely stored

in one of the researcher’s home offices. To maintain confidentiality, the JH interviewer will only

listen to the JH tapes and the HGH interviewer will only listen to the HGH tapes. The researchers

will then discuss both data sets, paying careful attention to how the data was coded. This strategy

strengthens the dependability of the research (Cypress, 2017). Staff identifiers will be left out.

Member checking allows for the data to be reviewed by the participants to verify its

accuracy and completeness (Macnee, 2012). It strengthens the credibility of qualitative research

(Bhattacherjee, 2012). For this reason, participants will be contacted by their site administrator

for a follow up interview. Once the data is verified, the needs and strategies identified under each

area of worklife would then serve the basis for the multidimensional approach to burnout

management. Asking a similar sample of participants if they agree with a study’s results, is

known as external checking (Macnee, 2004). This strategy strengthens the transferability of

qualitative research (Bhattacherjee, 2012). The results of this study will be shared with the same

cohort of ICU nurses that participated in the practice interviews before the study began.

Strengths and Limitations

Qualitative studies must be conducted with rigor due to the inherent subjectivity within

them (Cypress, 2017). The following strategies will be employed to ensure that the four criteria

for rigor are satisfied (dependability, confirmability, credibility, and transferability): bracketing,

keeping detailed observational notes and an audit trail, agreement between researchers for both

data sets, member checking and external checking. However, limitations exist. Inherent to any

phenomenological design, and to purposive sampling, is that researchers are prevented from

making inferences about the population at large (Etikan, Abubakar Sulaiman & Sunusi Alkassim,


2016). Despite the measures that will be taken to control for the researchers’ biases, it is possible

that these biases interfered with either data collection, analysis, or both. Recall bias is also

possible because participants were asked to share experiences that may have occurred some time

ago, preventing an accurate account of their burnout experience.

Discussion

This study’s results will be shared with the ICUs involved in this study, via the unit

distribution lists, and posted on the HHS intranet site. It will also be tweeted to @HHS_staff.

Critical care nurses are managing their exposure to workplace adversity the best they can, but to

no avail. They are burnt out. Overlapping conditions often co-exist, particularly moral distress.

The researchers hope is that after conducting interviews with ICU nurses at HHS, there will be

some clarity into what they view as roadblocks to their ability to thrive and practice resiliency.

Their insight can offer hope in the journey to addressing burnout in critical care.


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Appendix A

Jackson et al’s (2018), Managing Exposure Theory

Adapted from “Burnout and resilience in critical care nurses: A grounded theory of managing exposure,” by J. Jackson, V. Vandall-Walker, B. Vanderspank-Wright, P. Wishart & S.L. Moore, 2018, Intensive & Critical Care Nursing, 48, p. 30. Copyright 2018 by Crown Copyright


Appendix B

Multidimensional Workplace Interventions to Prevent and Treat Burnout in Critical Care

Adapted from “An official critical care societies collaborative statement: Burnout Syndrome in critical care health care professionals: A call for action,” by M. Moss, V.S. Good, D. Gozal, R. Kleinpell, C. N. Sessler, 2016, American Journal of Critical Care, 25(4), p. 373


Appendix C

Multidimensional Environmental Characteristics Contributing to Unrelieved Job Stress in ICU

Adapted from “Factors that influence pediatric intensive care unit nurses to leave their jobs,” by D.C. Foglia & J.S. Grassley, Critical Care Nurse Quarterly, 2010, 33(4), p. 308. Copyright 2010 by Lippincott Williams & Wilkins


Appendix D

Recruitment Flyer Emailed to Staff

SEEKING PARTICIPANTS FOR A RESEARCH STUDY

BURNOUT IN CRITICAL CARE NURSING

We are seeking to understand how to better manage burnout in the critical care setting and we need your input!

Are you willing to share your story of what burnout in critical care means to you? Have you worked in JH or HGH ICU for at least one year?

Participants will be asked to take part in a face-to-face audiotaped interview.Information shared will be kept strictly confidential.

Image taken from INSCOL India Blog: Code Blue

If you find that you sometimes feel or do the following at work, you may be suffering from burnout!

Are you coping with generalized fatigue from devoting time and energy to something that you do not perceive as being beneficial?

Do you find yourself emotionally detached from your work? Are you cynical in the manner in which you approach your work? Do you interact with others in an impersonal or dehumanized way? Do you negatively view the value of your work? (Moss et al., 2016).

If you’re interested in participating, or have any questions, please contact (ICU site administrator) at this email.

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