Vol. 149 No. 1112 (2019)
Teamwork and clinician burnout in Swiss intensive care: the predictive role of workload, and demographic and unit characteristics
- Annalena Welp
- Hans U. Rothen
- Paola Massarotto
- Tanja Manser
The levels of teamwork and clinician burnout in healthcare differ depending on demographic and unit characteristics. However, the impact of these characteristics varies between clinical settings. In addition, the impact of objectively measured workload in such settings is largely unknown. The aim of this study was to analyse the predictive role of demographic (e.g., professional experience) and unit (e.g., unit size) characteristics, and workload (e.g., nursing interventions) in explaining teamwork and clinician burnout in Swiss intensive care units (ICUs).
This was as cross-sectional multi-source study. Participants were 1148 nurses and 243 physicians working in 55 ICUs. They provided demographic information and answered a questionnaire on teamwork and clinician burnout. In addition, unit characteristics and surrogate measures of workload were extracted from a central database that accumulates patient and unit data routinely collected by the ICUs. We conducted multilevel regression analyses to detect relationships between study variables.
Clinicians who worked predominantly dayshifts reported better teamwork and lower burnout. Physicians and clinicians in leadership positions also reported better teamwork. Clinicians in leadership positions furthermore reported higher personal accomplishment, whereas clinicians in training reported higher emotional exhaustion. Of the unit characteristics, workload was positively associated with self-reported burnout. Clinicians working in medical and surgical ICUs (compared with interdisciplinary and paediatric ICUs) reported higher emotional exhaustion. Clinicians working in university hospitals and in surgical/medical ICUs reported lower teamwork quality and higher burnout.
We identified several demographic and unit-based factors in Swiss ICUs that were associated with lower perceptions of the quality of teamwork and higher self-reported burnout. Discrepant experiences regarding the quality of teamwork based on professional role, professional status and experience might affect team effectiveness. Furthermore, this study showed the importance of workload management, as objectively measured workload was associated with higher self-reported burnout. Results suggested that certain clinician groups (e.g., working predominantly night shifts) were at higher risk for burnout, thus highlighting the importance of providing additional support to these groups. Lastly, special attention should be paid to medical and surgical ICUs, which reported the highest level of burnout. Because this is a cross-sectional study, no conclusions can be drawn regarding causal relationships.
- Welp A, Meier LL, Manser T. The interplay between teamwork, clinicians’ emotional exhaustion, and clinician-rated patient safety: a longitudinal study. Crit Care. 2016;20(1):110. doi:.https://doi.org/10.1186/s13054-016-1282-9
- Spence Laschinger HK, Leiter MP. The impact of nursing work environments on patient safety outcomes: the mediating role of burnout/engagement. J Nurs Adm. 2006;36(5):259–67. doi:.https://doi.org/10.1097/00005110-200605000-00019
- Rathert C, Ishqaidef G, May DR. Improving work environments in health care: test of a theoretical framework. Health Care Manage Rev. 2009;34(4):334–43. doi:.https://doi.org/10.1097/HMR.0b013e3181abce2b
- Lingard L, Espin S, Evans C, Hawryluck L. The rules of the game: interprofessional collaboration on the intensive care unit team. Crit Care. 2004;8(6):R403–8. doi:.https://doi.org/10.1186/cc2958
- Vincent J-L, Creteur J. Paradigm shifts in critical care medicine: the progress we have made. Crit Care. 2015;19(Suppl 3):S10.
- Manthous C, Nembhard IM, Hollingshead AB. Building effective critical care teams. Crit Care. 2011;15(4):307. doi:.https://doi.org/10.1186/cc10255
- Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med. 2003;31(3):956–9. doi:.https://doi.org/10.1097/01.CCM.0000056183.89175.76
- Barzallo Salazar MJ, Minkoff H, Bayya J, Gillett B, Onoriode H, Weedon J, et al. Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. J Am Coll Surg. 2014;219(5):1001–7. doi:.https://doi.org/10.1016/j.jamcollsurg.2014.07.933
- Reid J, Bromiley M. Clinical human factors: the need to speak up to improve patient safety. Nurs Stand. 2012;26(35):35–40. doi:.https://doi.org/10.7748/ns2012.05.26.35.35.c9084
- Kolbe M, Burtscher MJ, Wacker J, Grande B, Nohynkova R, Manser T, et al. Speaking up is related to better team performance in simulated anesthesia inductions: an observational study. Anesth Analg. 2012;115(5):1099–108. doi:.https://doi.org/10.1213/ANE.0b013e318269cd32
- Estryn-Behar M, Doppia MA, Guetarni K, Fry C, Machet G, Pelloux P, et al. Emergency physicians accumulate more stress factors than other physicians-results from the French SESMAT study. Emerg Med J. 2011;28(5):397–410. doi:.https://doi.org/10.1136/emj.2009.082594
- Montgomery A, Spânu F, Băban A, Panagopoulou E. Job demands, burnout, and engagement among nurses: A multi-level analysis of ORCAB data investigating the moderating effect of teamwork. Burn Res. 2015;2(2-3):71–9. doi:.https://doi.org/10.1016/j.burn.2015.06.001
- Merlani P, Verdon M, Businger A, Domenighetti G, Pargger H, Ricou B ; STRESI+ Group. Burnout in ICU caregivers: a multicenter study of factors associated to centers. Am J Respir Crit Care Med. 2011;184(10):1140–6. doi:.https://doi.org/10.1164/rccm.201101-0068OC
- Chen KY, Yang CM, Lien CH, Chiou HY, Lin MR, Chang HR, et al. Burnout, job satisfaction, and medical malpractice among physicians. Int J Med Sci. 2013;10(11):1471–8. doi:.https://doi.org/10.7150/ijms.6743
- Bratt MM, Broome M, Kelber S, Lostocco L. Influence of stress and nursing leadership on job satisfaction of pediatric intensive care unit nurses. Am J Crit Care. 2000;9(5):307–17.
- Rafferty AM, Ball J, Aiken LH. Are teamwork and professional autonomy compatible, and do they result in improved hospital care? Qual Health Care. 2001;10(Suppl 2):ii32–7.
- Azoulay E, Herridge M. Understanding ICU staff burnout: the show must go on. Am J Respir Crit Care Med. 2011;184(10):1099–100. doi:.https://doi.org/10.1164/rccm.201109-1638ED
- Aiken LH, Sermeus W, Van den Heede K, Sloane DM, Busse R, McKee M, et al. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012;344(mar20 2):e1717. doi:.https://doi.org/10.1136/bmj.e1717
- Garrouste-Orgeas M, Perrin M, Soufir L, Vesin A, Blot F, Maxime V, et al. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture. Intensive Care Med. 2015;41(2):273–84. doi:.https://doi.org/10.1007/s00134-014-3601-4
- Murthy S, Wunsch H. Clinical review: International comparisons in critical care - lessons learned. Crit Care. 2012;16(2):218. doi:.https://doi.org/10.1186/cc11140
- Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Appl Psychol. 2001;86(3):499–512. doi:.https://doi.org/10.1037/0021-9010.86.3.499
- Geurts S, Rutte C, Peeters M. Antecedents and consequences of work-home interference among medical residents. Soc Sci Med. 1999;48(9):1135–48. doi:.https://doi.org/10.1016/S0277-9536(98)00425-0
- Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5):358–67. doi:.https://doi.org/10.7326/0003-4819-136-5-200203050-00008
- Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89(3):443–51. doi:.https://doi.org/10.1097/ACM.0000000000000134
- Carney BT, West P, Neily J, Mills PD, Bagian JP. Differences in nurse and surgeon perceptions of teamwork: implications for use of a briefing checklist in the OR. AORN J. 2010;91(6):722–9. doi:.https://doi.org/10.1016/j.aorn.2009.11.066
- Kristensen S, Hammer A, Bartels P, Suñol R, Groene O, Thompson CA, et al. Quality management and perceptions of teamwork and safety climate in European hospitals. Int J Qual Health Care. 2015;27(6):499–506. doi:.https://doi.org/10.1093/intqhc/mzv079
- Pronovost PJ, Jenckes MW, Dorman T, Garrett E, Breslow MJ, Rosenfeld BA, et al. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA. 1999;281(14):1310–7. doi:.https://doi.org/10.1001/jama.281.14.1310
- Schmalenberg C, Kramer M. Types of intensive care units with the healthiest, most productive work environments. Am J Crit Care. 2007;16(5):458–68, quiz 469.
- Shirom A, Nirel N, Vinokur AD. Work hours and caseload as predictors of physician burnout: The mediating effects by perceived workload and by autonomy. Appl Psychol. 2010;59(4):539–65.
- Guenther U, Koegl F, Theuerkauf N, Maylahn J, Andorfer U, Weykam J, et al. Pflegeaufwandsindizes TISS-10, TISS-28 und NEMS [Nursing workload indices TISS-10, TISS-28, and NEMS]. Med Klin Intensivmed Notf Med. 2016;111(1):57–64. doi:. [German.].https://doi.org/10.1007/s00063-015-0056-5
- Miranda DR, Moreno R, Iapichino G. Nine equivalents of nursing manpower use score (NEMS). Intensive Care Med. 1997;23(7):760–5. doi:.https://doi.org/10.1007/s001340050406
- Couchman BA, Wetzig SM, Coyer FM, Wheeler MK. Nursing care of the mechanically ventilated patient: what does the evidence say? Part one. Intensive Crit Care Nurs. 2007;23(1):4–14. doi:.https://doi.org/10.1016/j.iccn.2006.08.005
- Brandl KM, Langley KA, Riker RR, Dork LA, Quails CR, Levy H. Confirming the reliability of the sedation-agitation scale administered by ICU nurses without experience in its use. Pharmacotherapy. 2001;21(4):431–6. doi:.https://doi.org/10.1592/phco.21.5.431.34487
- Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999;27(7):1325–9. doi:.https://doi.org/10.1097/00003246-199907000-00022
- Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338–44. doi:.https://doi.org/10.1164/rccm.2107138
- Schweizer Gesellschaft fuer Intensivmedizin (SGI) [Internet]. Minimaler Datensatz der SGI MDSi. Basel: SGI. 2013. German. Current version available from https://www.sgi-ssmi.ch/de/datensatz.html?file=files/Dateiverwaltung/de/ressorts/quali/datsa/MDSiV27d.pdf
- Carmona-Monge FJ, Rollán Rodríguez GM, Quirós Herranz C, García Gómez S, Marín-Morales D. Evaluation of the nursing workload through the Nine Equivalents for Nursing Manpower Use Scale and the Nursing Activities Score: a prospective correlation study. Intensive Crit Care Nurs. 2013;29(4):228–33. doi:.https://doi.org/10.1016/j.iccn.2013.03.003
- Rothen HU, Küng V, Ryser DH, Zürcher R, Regli B. Validation of “nine equivalents of nursing manpower use score” on an independent data sample. Intensive Care Med. 1999;25(6):606–11. doi:.https://doi.org/10.1007/s001340050910
- Ausserhofer D, Schubert M, Blegen M, De Geest S, Schwendimann R. Validity and reliability on three European language versions of the Safety Organizing Scale. Int J Qual Health Care. 2013;25(2):157–66. doi:.https://doi.org/10.1093/intqhc/mzt001
- Vogus TJ, Sutcliffe KM. The Safety Organizing Scale: development and validation of a behavioral measure of safety culture in hospital nursing units. Med Care. 2007;45(1):46–54. doi:.https://doi.org/10.1097/01.mlr.0000244635.61178.7a
- Ausserhofer D, Desmedt M, Schubert M, Schwendimann R, De Geest S. RN4Cast – Schweizer Ergebnisse der weltweit grössten Outcome-Studie in der Pflege. Pflegenetz. 2012:4-7. German.
- Lake ET. Development of the practice environment scale of the Nursing Work Index. Res Nurs Health. 2002;25(3):176–88. doi:.https://doi.org/10.1002/nur.10032
- Sermeus W, Aiken LH, Van den Heede K, Rafferty AM, Griffiths P, Moreno-Casbas MT, et al.; RN4CAST consortium. Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology. BMC Nurs. 2011;10(1):6. doi:.https://doi.org/10.1186/1472-6955-10-6
- Büssing A, Glaser J. Managerial Stress und Burnout. A Collaborative International Study (CISMS). Die deutsche Untersuchung. München: Technische Universität, Lehrstuhl für Psychologie; 1998. German.
- Dion G, Tessier R. Validation de la traduction de l’Inventaire d’épuisement professionnel de Maslach et Jackson. Can J Behav Sci. 1994;26(2):210–27. doi:. [French.].https://doi.org/10.1037/0008-400X.26.2.210
- Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. Palo Alto, CA: Consulting Psychologists Press; 1996.
- Pisanti R, Lombardo C, Lucidi F, Violani C, Lazzari D. Psychometric properties of the Maslach Burnout Inventory for Human Services among Italian nurses: a test of alternative models. J Adv Nurs. 2013;69(3):697–707. doi:.https://doi.org/10.1111/j.1365-2648.2012.06114.x
- Cannon-Bowers JA, Salas E, Converse S. Shared mental models in expert team decision making. In: Castellan NJ, editor. Individual and group decision making. Hillsdale, NJ: Lawrence Erlbaum Associates; 1993. p. 221-46.
- Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350–83. doi:.https://doi.org/10.2307/2666999
- Baer M, Frese M. Innovation is not enough: climates for initiative and psychological safety, process innovations, and firm performance. J Organ Behav. 2003;24(1):45–68. doi:.https://doi.org/10.1002/job.179
- Muthén LK, Muthén BO. Mplus User's Guide. 6th ed. Los Angeles, CA: Muthén & Muthén; 2012.
- Hardy MA. Regression with dummy variables. Newbury Park, CA: Sage; 1993.
- George D, Mallery M. SPSS for windows step by step: A simple guide and reference, 17.0 update. 10th ed. Boston: Pearson; 2010.
- Hox JJ. Multilevel analysis. Techniques and applications. 2nd ed. New York: Routledge; 2010.
- Van der Veg GS, Bunderson JS. Learning and performance in mutlidisciplinary teams: The importance of collective tem identification. Acad Manage J. 2005;48(3):532–47.
- Vargas C, Cañadas GA, Aguayo R, Fernández R, de la Fuente EI. Which occupational risk factors are associated with burnout in nursing? A meta-analytic study. Int J Clin Health Psychol. 2014;14(1):28–38. doi:.https://doi.org/10.1016/S1697-2600(14)70034-1
- Nilsson K, Campbell A-M, Andersson EP. Night nursing - staff’s working experiences. BMC Nurs. 2008;7(1):13. doi:.https://doi.org/10.1186/1472-6955-7-13
- Powell I. Can you see me? Experiences of nurses working night shift in Australian regional hospitals: a qualitative case study. J Adv Nurs. 2013;69(10):2172–84. doi:.https://doi.org/10.1111/jan.12079
- Muecke S. Effects of rotating night shifts: literature review. J Adv Nurs. 2005;50(4):433–9. doi:.https://doi.org/10.1111/j.1365-2648.2005.03409.x
- Admi H, Tzischinsky O, Epstein R, Herer P, Lavie P. Shift work in nursing: is it really a risk factor for nurses’ health and patients’ safety? Nurs Econ. 2008;26(4):250–7.
- Rogers AE, Hwang W-T, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Aff (Millwood). 2004;23(4):202–12. doi:.https://doi.org/10.1377/hlthaff.23.4.202
- Ayanian JZ, Weissman JS. Teaching hospitals and quality of care: a review of the literature. Milbank Q. 2002;80(3):569–93, v. doi:.https://doi.org/10.1111/1468-0009.00023
- Martín-Lesende I, Recalde E, Viviane-Wunderling P, Pinar T, Borghesi F, Aguirre T, et al. Mortality in a cohort of complex patients with chronic illnesses and multimorbidity: a descriptive longitudinal study. BMC Palliat Care. 2016;15(1):42. doi:.https://doi.org/10.1186/s12904-016-0111-x
- Perren A, Cerutti B, Merlani P, Perren I, Previsdomini M, Massarotto P, et al. SwissScoring--a nationwide survey of NEMS assessing practices and its accuracy. Acta Anaesthesiol Scand. 2014;58(4):478–86. doi:.https://doi.org/10.1111/aas.12283
- Perren A, Previsdomini M, Perren I, Merlani P. High accuracy of the nine equivalents of nursing manpower use score assessed by critical care nurses. Swiss Med Wkly. 2012;142:w13555. doi:.https://doi.org/10.4414/smw.2012.13555
- Burtscher MJ, Kolbe M, Wacker J, Manser T. Interactions of team mental models and monitoring behaviors predict team performance in simulated anesthesia inductions. J Exp Psychol Appl. 2011;17(3):257–69. doi:.https://doi.org/10.1037/a0025148
- Endacott R, Bogossian FE, Cooper SJ, Forbes H, Kain VJ, Young SC, et al.; First2Act Team. Leadership and teamwork in medical emergencies: performance of nursing students and registered nurses in simulated patient scenarios. J Clin Nurs. 2015;24(1-2):90–100. doi:.https://doi.org/10.1111/jocn.12611
- Schraagen JM, Schouten T, Smit M, Haas F, van der Beek D, van de Ven J, et al. A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. BMJ Qual Saf. 2011;20(7):599–603. doi:.https://doi.org/10.1136/bmjqs.2010.048983
- Aronsson G, Theorell T, Grape T, Hammarström A, Hogstedt C, Marteinsdottir I, et al. A systematic review including meta-analysis of work environment and burnout symptoms. BMC Public Health. 2017;17(1):264. doi:.https://doi.org/10.1186/s12889-017-4153-7
- DeChurch LA, Mesmer-Magnus JR. The cognitive underpinnings of effective teamwork: a meta-analysis. J Appl Psychol. 2010;95(1):32–53. doi:.https://doi.org/10.1037/a0017328
- De Dreu CK, Weingart LR. Task versus relationship conflict, team performance, and team member satisfaction: a meta-analysis. J Appl Psychol. 2003;88(4):741–9. doi:.https://doi.org/10.1037/0021-9010.88.4.741
- Bakker AB, Le Blanc PM, Schaufeli WB. Burnout contagion among intensive care nurses. J Adv Nurs. 2005;51(3):276–87. doi:.https://doi.org/10.1111/j.1365-2648.2005.03494.x
- Arigoni F, Bovier PA, Sappino AP. Trend of burnout among Swiss doctors. Swiss Med Wkly. 2010;140:w13070.
- Toppinen-Tanner S, Ojajärvi A, Väänänen A, Kalimo R, Jäppinen P. Burnout as a predictor of medically certified sick-leave absences and their diagnosed causes. Behav Med. 2005;31(1):18–27. doi:.https://doi.org/10.3200/BMED.31.1.18-32
- Andel C, Davidow SL, Hollander M, Moreno DA. The economics of health care quality and medical errors. J Health Care Finance. 2012;39(1):39–50.